Overview

Depression is a disabling illness that affects about 15% to 25% of cancer patients. It affects men and women with cancer equally. People who face a diagnosis of cancer will experience different levels of stress and emotional upset. Important issues in the life of any person with cancer may include the following:

• Fear of death.
• Interruption of life plans.
• Changes in body image and self-esteem.
• Changes in social role and lifestyle.
• Money and legal concerns.

Everyone who is diagnosed with cancer will react to these issues in different ways and may not experience serious depression or anxiety.

Palliative care begins at diagnosis and continues throughout the patient's cancer care. Patients who are receiving palliative care for cancer during the last 6 months of life may have frequent feelings of depression and anxiety, leading to a much lower quality of life. During this time, patients in palliative care who suffer from depression report being more troubled about their physical symptoms, relationships, and beliefs about life. Depressed terminally ill patients have reported feelings of "being a burden" even when the actual amount of dependence on others is small.

Just as patients need to be evaluated for depression throughout their treatment, so do family caregivers. Caregivers have been found to experience a good deal more anxiety and depression than people who are not caring for patients with cancer. Children are also affected when a parent with cancer develops depression. A study of women with breast cancer showed that children of depressed patients were the most likely to have emotional and behavioral problems themselves.

There are many misconceptions about cancer and how people cope with it, such as the following:

• All people with cancer are depressed.
• Depression in a person with cancer is normal.
• Treatment does not help the depression.
• Everyone with cancer faces suffering and a painful death.

Sadness and grief are normal reactions to the crises faced during cancer, and will be experienced at times by all people. Because sadness is common, it is important to distinguish between normal levels of sadness and depression. An important part of cancer care is the recognition of depression that needs to be treated. Some people may have more trouble adjusting to the diagnosis of cancer than others may. Major depression is not simply sadness or a blue mood. Major depression affects about 25% of patients and has common symptoms that can be diagnosed and treated. Symptoms of depression that are noticed when a patient is diagnosed with cancer may be a sign that the patient had a depression problem before the diagnosis of cancer.

All people will experience reactions of sadness and grief periodically throughout diagnosis, treatment, and survival of cancer. When people find out they have cancer, they often have feelings of disbelief, denial, or despair. They may also experience difficulty sleeping, loss of appetite, anxiety, and a preoccupation with worries about the future. These symptoms and fears usually lessen as a person adjusts to the diagnosis. Signs that a person has adjusted to the diagnosis include an ability to maintain active involvement in daily life activities, and an ability to continue functioning as spouse, parent, employee, or other roles by incorporating treatment into his or her schedule. If the family of a patient diagnosed with cancer is able to express feelings openly and solve problems effectively, both the patient and family members have less depression. Good communication within the family reduces anxiety. A person who cannot adjust to the diagnosis after a long period of time, and who loses interest in usual activities, may be depressed. Mild symptoms of depression can be distressing and may be helped with counseling. Even patients without obvious symptoms of depression may benefit from counseling; however, when symptoms are intense and long-lasting, or when they keep coming back, more intensive treatment is important.

Diagnosis

The symptoms of major depression include the following:

• Having a depressed mood for most of the day and on most days.

• Loss of pleasure and interest in most activities.

• Changes in eating and sleeping habits.

• Nervousness or sluggishness.

• Tiredness.

• Feelings of worthlessness or inappropriate guilt.

• Poor concentration.

• Constant thoughts of death or suicide.

To make a diagnosis of depression, these symptoms should be present on most days for at least 2 weeks. The diagnosis of depression can be difficult to make in people with cancer due to the difficulty of separating the symptoms of depression from the side effects of medications or the symptoms of cancer. This is especially true in patients undergoing active cancer treatment or those with advanced disease. Symptoms of guilt, worthlessness, hopelessness, thoughts of suicide, and loss of pleasure are the most useful in diagnosing depression in people who have cancer.

Some people with cancer may have a higher risk for developing depression. The cause of depression is not known, but the risk factors for developing depression are known. Risk factors may be cancer-related and noncancer-related.

• Cancer-Related Risk Factors:
  • Depression at the time of cancer diagnosis.
  • Poorly controlled pain.
  • An advanced stage of cancer.
  • Increased physical impairment or pain.
  • Pancreatic cancer.
  • Being unmarried and having head and neck cancer.
  • Treatment with some anticancer drugs.

• Noncancer-Related Risk Factors:
  • History of depression.
  • Lack of family support.
  • Other life events that cause stress.
  • Family history of depression or suicide.
  • Previous suicide attempts.
  • History of alcoholism or drug abuse.
  • Having many illnesses at the same time that produce symptoms of depression (such as stroke or heart attack).

The evaluation of depression in people with cancer should include a careful evaluation of the person's thoughts about the illness; medical history; personal or family history of depression or suicide; current mental status; physical status; side effects of treatment and the disease; other stresses in the person's life; and support available to the patient. Thinking of suicide, when it occurs, is frightening for the individual, for the health care worker, and for the family. Suicidal statements may range from an offhand comment resulting from frustration or disgust with a treatment course, such as "If I have to have one more bone marrow aspiration this year, I'll jump out the window," to a statement indicating deep despair and an emergency situation, such as, "I can't stand what this disease is doing to all of us, and I am going to kill myself." Exploring the seriousness of these thoughts is important. If the thoughts of suicide seem to be serious, then the patient should be referred to a psychiatrist or psychologist, and the safety of the patient should be secured.

The most common type of depression in people with cancer is called reactive depression. This shows up as feeling moody and being unable to perform usual activities. The symptoms last longer and are more pronounced than a normal and expected reaction but do not meet the criteria for major depression. When these symptoms greatly interfere with a person's daily activities, such as work, school, shopping, or caring for a household, they should be treated in the same way that major depression is treated (such as crisis intervention, counseling, and medication, especially with drugs that can quickly relieve distressing symptoms). Basing the diagnosis on just these symptoms can be a problem in a person with advanced cancer since the illness may be causing decreased functioning. It is important to identify the difference between fatigue and depression since they can be assessed and treated separately. In more advanced illness, focusing on despair, guilty thoughts, and a total lack of enjoyment of life is helpful in diagnosing depression. (Refer to the PDQ summary on Adjustment to Cancer: Anxiety and Distress for further information.)

Medical factors may also cause symptoms of depression in patients with cancer. Medication usually helps this type of depression more effectively than counseling, especially if the medical factors cannot be changed (for example, dosages of the medications that are causing the depression cannot be changed or stopped). Some medical causes of depression in patients with cancer include uncontrolled pain; abnormal levels of calcium, sodium, or potassium in the blood; anemia; vitamin B ₁₂ or folate deficiency; fever; and abnormal levels of thyroid hormone or steroids in the blood.

Treatment

Major depression may be treated with a combination of counseling and medications (drugs), such as antidepressants. A primary care doctor may prescribe medications for depression and refer the patient to a psychiatrist or psychologist for the following reasons:

• A physician or oncologist is not comfortable treating the depression (for example, the patient has suicidal thoughts).

• The symptoms of depression do not improve after 2 to 4 weeks of treatment.

• The symptoms are getting worse.

• The side effects of the medication keep the patient from taking the dosage needed to control the depression.

• The symptoms are interfering with the patient's ability to continue medical treatment.

Antidepressants are usually effective in the treatment of depression and its symptoms. Unfortunately, antidepressants are not prescribed often for patients with cancer. About 25% of all patients are depressed, but only about 16% receive medication for the depression. The choice of antidepressant depends on the patient's symptoms, potential side effects of the antidepressant, and the person's individual medical problems and previous response to antidepressant drugs.

The Food and Drug Administration (FDA) has issued a warning that patients who are taking antidepressants, such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro), bupropion (Wellbutrin), venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron), should be closely monitored for signs of worsening depression and suicidal thoughts. A Patient Medication Guide (MedGuide) should also be given to patients receiving antidepressants to warn them of the risk and suggest precautions that can be taken.

The FDA has also directed manufacturers of all antidepressant drugs to change the labeling for their products to include a boxed warning and more detailed warning statements about increased risk of suicidal thinking and behavior in children and adolescents being treated with antidepressants. Some studies show that the benefits of proper antidepressant use in children and adolescents, including careful monitoring for suicidal behavior, may outweigh the risks. However, for children younger than 12 years with major depression, only fluoxetine (Prozac) showed benefit compared to a placebo.

Patients with cancer may be treated with a number of drugs throughout their care. Some drugs do not mix safely with certain other drugs, foods, herbals, and nutritional supplements. Certain combinations may reduce or change how drugs work or cause life-threatening side effects. It is important that the patient's healthcare providers be told about all the drugs, herbals, and nutritional supplements the patient is taking, including drugs taken in patches on the skin. This can help prevent unwanted reactions.

St. John's wort (Hypericum perforatum) has been used as an over-the-counter supplement to treat depression. Many studies have been done to compare St. John's wort with antidepressants, placebo (inactive) drugs, or both, and have shown mixed results. An overview of 37 randomized, controlled clinical trials in patients with depression showed that St. John's wort does not have a strong effect on major depression, but may have a slight effect on mild depression.

Side effects reported in studies of St. John's wort are minor. An overview of clinical trials comparing St. John's wort with antidepressants found that fewer patients dropped out of studies due to side effects of St. John's wort than due to side effects of antidepressants.

Patients with symptoms of depression should not self-treat with St. John's wort. This supplement may change the way certain drugs act in the body. Patients should see a doctor to review their current medications before taking St. John's wort to avoid possible drug interactions.

Cautions about using St. John's wort for depression include the following:

• St. John's wort is regulated by the FDA as an herbal supplement/food, not as a drug. The amount of active ingredients in St. John's wort preparations is not standardized and may differ by brand.

• St. John's wort can make certain drugs less effective, including:
  • Irinotecan and possibly docetaxel for the treatment of cancer.
  • Cyclosporin A and tacrolimus to lower the risk of organ and bone marrow transplant rejection.
  • Indinavir for the treatment of HIV.

St. John's wort is not recommended as a treatment for depression due to its lack of strong effect, lack of standardization, and possible interaction with other medications.

Most antidepressants take 3 to 6 weeks to begin working. The side effects must be considered when deciding which antidepressant to use. For example, a medication that causes sleepiness may be helpful in an anxious patient who is having problems sleeping, since the drug is both calming and sedating. Patients who cannot swallow pills may be able to take the medication as a liquid or as an injection. If the antidepressant helps the symptoms, treatment should continue for at least 6 months. Electroconvulsive therapy (ECT) is a useful and safe therapy when other treatments have been unsuccessful in relieving major depression.

Several psychiatric therapies have been found to be helpful in the treatment of depression related to cancer. Most therapy programs for depression are given in 4 to 30 hours and are offered in both individual and group settings. They may include sessions about cancer education or relaxation skills. These therapies are often used in combination and include crisis intervention, psychotherapy, and thought/behavior techniques. Patients explore methods of lowering distress, improving coping and problem-solving skills; enlisting support; reshaping negative and self-defeating thoughts; and developing a close personal bond with an understanding health care provider. Talking with a clergy member may also be helpful for some people.

Specific goals of these therapies include the following:

• Assist people diagnosed with cancer and their families by answering questions about the illness and its treatment, explaining information, correcting misunderstandings, giving reassurance about the situation, and exploring with the patient how the diagnosis relates to previous experiences with cancer.

• Assist with problem solving, improve the patient's coping skills, and help the patient and family to develop additional coping skills. Explore other areas of stress, such as family role and lifestyle changes, and encourage family members to support and share concern with each other.

• Ensure that the patient and family understand that support will continue when the focus of treatment changes from trying to cure the cancer to relieving symptoms. The health care team will treat symptoms to help the patient control pain and remain comfortable, and will help the patient and his or her family members maintain dignity.

Cancer support groups may also be helpful in treating depression in patients with cancer, especially adolescents. Support groups have been shown to improve mood, encourage the development of coping skills, improve quality of life, and improve immune response. Support groups can be found through the wellness community, the American Cancer Society, and many community resources, including the social work departments in medical centers and hospitals.

Recent studies of psychotherapy in patients with cancer, including training in problem solving, have shown that it helps decrease feelings of depression.

Check NCI’s list of cancer clinical trials for U.S. supportive and palliative care trials about depression that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Evaluation and Treatment of Suicidal Patients with Cancer

The incidence of suicide in cancer patients may be as much as 10 times higher than the rate of suicide in the general population. One study has shown that the risk of suicide in patients with cancer is highest in the first months after diagnosis, and that this risk decreases significantly over decades. Passive suicidal thoughts are fairly common in patients with cancer. The relationships between suicidal tendency and the desire for hastened death, requests for physician -assisted suicide, and/or euthanasia are complicated and poorly understood. Men with cancer are at an increased risk of suicide compared with the general population, with more than twice the risk. Overdosing with painkillers and sedatives is the most common method of suicide by patients with cancer, with most cancer suicides occurring at home. The occurrence of suicide is higher in patients with oral, pharyngeal, and lung cancers, and in HIV-positive patients with Kaposi sarcoma. The actual incidence of suicide in cancer patients is probably underestimated, since there may be reluctance to report these deaths as suicides.

General risk factors for suicide in a person with cancer include the following:

• A history of mental problems, especially those associated with impulsive behavior (such as borderline personality disorders).
• A family history of suicide.
• A history of suicide attempts.
• Depression.
• Substance abuse.
• Recent death of a friend or spouse.
• Having little social support.

Cancer-specific risk factors for suicide include the following:

• A diagnosis of oral, throat, or lung cancer (often associated with heavy alcohol and tobacco use).
• Advanced stage of disease and poor prognosis.
• Confusion /delirium.
• Poorly controlled pain.
• Physical impairments such as the following:
  • Loss of mobility.
  • Loss of bowel and bladder control.
  • Amputation.
  • Loss of eyesight or hearing.
  • Paralysis.
  • Inability to eat or swallow.
• Tiredness.
• Exhaustion.

Patients who are suicidal require careful evaluation. The risk of suicide increases if the patient reports thoughts of suicide and has a plan to carry it out. Risk continues to increase if the plan is "lethal," that is, the plan is likely to cause death. A lethal suicide plan is more likely to be carried out if the way chosen to cause death is available to the person, the attempt cannot be stopped once it is started, and help is unavailable. When a person with cancer reports thoughts of death, it is important to determine whether the underlying cause is depression or a desire to control unbearable symptoms. Prompt identification and treatment of major depression is important in decreasing the risk for suicide. Risk factors, especially hopelessness (which is a better predictor for suicide than depression) should be carefully determined. The assessment of hopelessness is not easy in the person who has advanced cancer with no hope of a cure. It is important to determine the basic reasons for hopelessness, which may be related to cancer symptoms, fears of painful death, or feelings of abandonment.

Talking about suicide will not cause the patient to attempt suicide; it actually shows that this is a concern and permits the patient to describe his or her feelings and fears, providing a sense of control. A crisis intervention -oriented treatment approach should be used which involves the patient's support system. Contributing symptoms, such as pain, should be aggressively controlled and depression, psychosis, anxiety, and underlying causes of delirium should be treated. These problems are usually treated in a medical hospital or at home. Although not usually necessary, a suicidal patient with cancer may need to be hospitalized in a psychiatric unit.

The goal of treatment of suicidal patients is to attempt to prevent suicide that is caused by desperation due to poorly controlled symptoms. Patients close to the end of life may not be able to stay awake without a great amount of emotional or physical pain. This often leads to thoughts of suicide or requests for aid in dying. Such patients may need sedation to ease their distress.

Other treatment considerations include using medications that work quickly to alleviate distress (such as antianxiety medication or stimulants) while waiting for the antidepressant medication to work; limiting the quantities of medications that are lethal in overdose; having frequent contact with a health care professional who can closely observe the patient; avoiding long periods of time when the patient is alone; making sure the patient has available support; and determining the patient's mental and emotional response at each crisis point during the cancer experience.

Pain and symptom treatment should not be sacrificed simply to avoid the possibility that a patient will attempt suicide. Patients often have a method to commit suicide available to them. Incomplete pain and symptom treatment might actually worsen a patient's suicide risk.

Frequent contact with the health professional can help limit the amount of lethal drugs available to the patient and family. Infusion devices that limit patient access to medications can also be used at home or in the hospital. These are programmable, portable pumps with coded access and a locked cartridge containing the medication. These pumps are very useful in controlling pain and other symptoms. Some pumps can give multiple drug infusions, and some can be programmed over the phone. The devices are available through home care agencies, but are very expensive. Some of the expense may be covered by insurance.

Suicide can make the loss of a loved one especially difficult for survivors. Survivors often have reactions that include feelings of abandonment, rejection, anger, relief, guilt, responsibility, denial, identification, and shame. These reactions are affected by the type and intensity of relationship; the nature of the suicide; the age and physical condition of the deceased; the survivor's support network and coping skills; and cultural and religious beliefs. Survivors should have help during this period of grieving. Mutual support groups can lessen isolation, provide opportunities to discuss feelings, and help survivors find ways to cope.

The reactions of health care providers to the suicide are similar to those seen in family members, although caregivers often do not feel they have the right to express their feelings.

Assisted Dying, Euthanasia, and Decisions Regarding End of Life

Respecting and promoting patient control has been one of the driving forces behind the hospice movement and right-to-die issues that range from honoring living wills to promoting euthanasia (mercy killing). These issues can create a conflict between a patient's desire for control and a physician's duty to promote health. These are issues of law, ethics, medicine, and philosophy. Some physicians may favor strong pain control and approve of the right of patients to refuse life support, but do not favor euthanasia or assisted suicide. Often patients who ask for physician-assisted suicide can be treated by increasing the patient's comfort and relieving symptoms, thereby reducing the patient's need for drastic measures. Patients with the desire to die should be carefully evaluated and treated for depression.

(See the PDQ summary on Last Days of Life for more information.)

Palliative Sedation

The decision whether to sedate a patient at the end of life is difficult and involves many factors. The goal of palliative sedation is not to shorten life but to make the end of life more comfortable. Palliative sedation may be considered in order to relieve uncontrolled physical suffering, depression, or anxiety. Certain drugs are given to sedate the patient and may be combined with treatment for pain and agitation. Palliative sedation may be temporary, as in patients with delirium or trouble breathing.

A patient's thoughts and feelings about end-of-life sedation may depend greatly on his or her own culture and beliefs. Some patients who are nearing the end of life may want to be sedated. Other patients may wish to have no procedures, including sedation, just before death. It is important for the patient to tell family members and health care providers of his or her wishes about sedation at the end of life. When patients make their wishes about sedation known ahead of time, doctors and family members can be sure they are doing what the patient would want.

Considerations for Depression in Children

Most children cope with the emotions related to cancer and not only adjust well, but show positive emotional growth and development. A small number of children, however, develop psychological problems including depression, anxiety, sleeping problems, relationship problems, and are uncooperative about treatment. A mental health specialist should treat these children.

Children with severe late effects of cancer have more symptoms of depression. Anxiety usually occurs in younger patients, while depression is more common in older children. Most cancer survivors are generally able to adapt and adjust successfully to cancer and its treatment; however, a small number of cancer survivors have difficulty adjusting.

The term depression refers to a symptom or a set of symptoms or conditions that occur together and suggest the presence of depression, or an illness. A diagnosis of depression as an illness depends on how severe the symptoms are and how long they last. For example, a child may be sad in response to trauma, and the sadness usually lasts a short time. Depression, however, is marked by a response that lasts a long time, and is associated with sleeplessness, irritability, changes in eating habits, and problems at school and with friends. Depression should be considered whenever any behavior problem continues. Depression does not refer to temporary moments of sadness, but rather to a disorder that affects development and interferes with the child's progress.

Some signs of depression in the school-aged child include the following:

• Not eating.
• Inactivity.
• Looking sad.
• Aggressive behavior.
• Crying.
• Hyperactivity.
• Physical complaints.
• Fear of death.
• Frustration.
• Feelings of sadness or hopelessness.
• Self-criticism.
• Frequent daydreaming.
• Low self-esteem.
• Refusing to go to school.
• Learning problems.
• Slow movements.
• Showing anger towards parents and teachers.
• Loss of interest in activities that were previously enjoyed.

Some of these signs can occur in response to normal developmental stages; therefore, it is important to determine whether they are related to depression or a developmental stage.

Determining a diagnosis of depression includes evaluating the child's family situation, as well as his or her level of emotional maturity and ability to cope with illness and treatment; the child's age and state of development; and the child's self esteem and prior experience with illness.

A comprehensive assessment for childhood depression is necessary for effective diagnosis and treatment. Evaluation of the child and family situation focuses on the child's health history; observations of the behavior of the child by parents, teachers, or healthcare workers; interviews with the child; and use of psychological tests.

Childhood depression and adult depression are different illnesses due to the developmental issues involved in childhood. The following criteria may also be used for diagnosing depression in children:

• A sad mood (and a sad facial expression in children younger than 6) with at least 4 of the following signs or symptoms present every day for a period of at least 2 weeks:
  • Appetite changes.
  • Either not sleeping or sleeping too much.
  • Being either too active or not active enough.
  • Loss of interest or pleasure in usual activities.
  • Signs of not caring about anything (in children younger than 6).
  • Tiredness or loss of energy.
  • Feelings of worthlessness.
  • Self-criticism or inappropriate guilt.
  • Inability to think or concentrate well.
  • Constant thoughts of death or suicide.

Individual and group counseling are usually used as the first treatment for a child with depression, and are directed at helping the child to master his or her difficulties and develop in the best way possible. Play therapy may be used as a way to explore the younger child's view of him- or herself, the disease, and treatment. From the beginning of treatment, a child needs help to understand, at his or her developmental level, the diagnosis of cancer and the treatment involved. A doctor may prescribe medications, such as antidepressants, for children. Some of the same antidepressants prescribed for adults may also be prescribed for children. (See the Treatment section for information about FDA warnings on antidepressant use in children and adolescents.)

For information about suicide in children and warnings about SSRI use, see the Depression and Suicide section in the PDQ summary on Pediatric Supportive Care.

Changes to This Summary (08/19/2011)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

Questions or Comments About This Summary

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