By Leslie J. Thompson

Bob Knol, PhD, considered himself lucky. The cancer in his prostate, detected early through a PSA test, was entirely contained within the gland. He needed no chemotherapy, no radiation treatment. Indeed, his prognosis was very good. But two years after his surgery, Dr. Knol found the joy had gone out of his life. “Ordinarily, I’m a pretty up, pretty extroverted person,” he says. But, “I felt sad,” he remembers. “I was less interactive and spontaneous.”

Dr. Knol’s experience with depression after cancer is hardly unique. In fact, while many might assume the experience of cancer should make those who have had it simply thrilled to be alive, statistics often show the opposite.

Studies indicate as many as 30 percent of cancer patients will meet diagnostic criteria for a depressive or anxiety disorder at some point during treatment, compared to around 10 percent of American adults who will experience clinically significant depression in a given year. What’s more, symptoms of depression are often unrecognized or untreated. But help is available in myriad forms, from support groups and psychological counseling to highly effective antidepressant medications.

That’s the route Dr. Knol chose (on a psychiatrist’s recommendation) after his wife finally nudged him into admitting he was depressed. Now, says Dr. Knol, who is a psychologist, “My old spark is back, both in terms of my sense of humor and my spontaneity. I don’t have the sadness that I had.”

A cancer diagnosis often brings feelings of sorrow, fear and anxiety— understandable reactions to the discovery that you have a potentially life-threatening condition.

“That kind of sadness is perfectly normal and is part of being human,” says Harvey Chochinov, MD, PhD, professor of psychiatry and director of the Manitoba Palliative Care Research Unit in Winnipeg, Canada. What is not normal, he notes, are enduring depressive symptoms, such as hopelessness, helplessness and pervasive thoughts of death and suicide, as well as physical symptoms, such as insomnia and a loss of appetite. This type of depression is an enduring condition in which negative thoughts and feelings can come to dominate peoples’ lives.

“I got really withdrawn,” recalls Rosemount, Minnesota, breast cancer survivor Joyce Peggs. “I was just going through the motions of life—and only the ones that were absolutely necessary. There wasn’t any joy in it.”

“Everything is negative. You can’t see the positive for all the negatives,” says Dwight Lee, MD, a Dallas-based ear, nose and throat specialist who was diagnosed with prostate cancer in late 1999.

In many instances, clinically significant depression can go undiagnosed in cancer patients, because many of the physical symptoms are similar for both illnesses. Problems with eating, sleeping and a lack of energy can also be side effects of certain cancer therapies and may not be recognized as indicators of psychological distress. In other cases, depression may go untreated because people assume it is simply part of the cancer experience.

“If healthcare providers hold the position that all sadness—even sadness associated with the full constellation of symptoms that comprise clinical depression—is normal, then a diagnosis and help will not be forthcoming,” says Dr. Chochinov, whose recent research has explored the impact that untreated depression can have on terminal cancer patients’ will to live.

But depression can and should be treated, even when a person is undergoing complicated regimens for cancer or other illnesses. What’s more, through the use of standardized distress guidelines, clinicians can more easily recognize symptoms of depression and manage them effectively.

William Breitbart, MD, chief of psychiatry service and attending psychiatrist in the Department of Psychiatry at Memorial Sloan-Kettering Cancer Center in New York, also emphasizes that depression should be addressed in even the sickest patients.

“Even when you would expect cancer patients to be depressed, those who have very advanced cancer, the reality is that studies show only around 17 to 20 percent have clinical depression,” Dr. Breitbart says.

And so one of the things that has to change, Dr. Breitbart notes, is the expectation on the part of the physician that patients will be naturally depressed if they have cancer, so there’s no point in treating it.

“I say if you walk across the street and get hit by a bus, it’s not unusual to have broken bones, but you don’t leave them there in the street,” he says.

Dr. Breitbart has found that those patients who express a desire for a hastened death have higher incidences of depression, but those feelings go away when they are treated for depression.

“These are people who are in so much despair that they want to die,” he says. “When you are depressed and in despair, your vision is constricted. You can’t see what else may help the suffering. My patients are smart people, and if they don’t have the right information to look at what can happen and if they are depressed and can’t see the options, it’s easy to see how they might come up with wanting to hasten death.”

Dr. Breitbart says there are many diagnostic methods and sophisticated studies to determine depression, but he has found the best indicator to be a positive response to one question: Have you been depressed most of the day every day for the past two weeks?

It’s the persistent depressed mood that is the indicator, he says. A couple of weeks is arbitrary but the point is that it’s chronic.

Dr. Breitbart also points out that suicidal ideation (thinking about suicide) is different than acceptance that death is coming. “Suicidal ideation is quite common for cancer patients as some kind of escape hatch in the future. ‘If things get really bad, I can commit suicide.’ Looking at it as a future option helps them cope. Looking at it for now is associated with depression and despair.”

Who is at Risk?

Several factors can influence the risk of depression, including the cancer itself. Recent studies have found that proteins called cytokines, which are sometimes produced by tumors and sometimes by the immunological response to tumors, “can cause a host of psychiatric symptoms, including depression, anxiety and confusion,” says Thomas Strouse, MD, director of psychosocial services and cancer pain management at Cedars-Sinai Comprehensive Cancer Center in Los Angeles.

Pancreatic and lung cancers are known to trigger depressive symptoms as well. “Some of this is related to hormones and neuroendocrine abnormalities that result from cancer,” explains Michelle Riba, MD, director of the Psycho-Oncology Program at the University of Michigan Comprehensive Cancer Center in Ann Arbor.

Similarly, certain cancer treatments can induce psychological distress. Some hormonal medications such as tamoxifen, some of the antitestosterone hormonal treatments for prostate cancer and biological agents like interferon are all associated with mood problems, says Dr. Riba. In addition, “many of the current chemo agents will have an impact on the central nervous system, including mood and memory (cognition).”

For Dr. Lee, it was a combination of the cancer diagnosis and the ensuing treatment that triggered the depression he has been struggling to manage for more than three years.

“One of the things that exacerbated my depression was that my tumor was classified as a T-3, so my possibility of recurrence was 40 percent,” he says. After dealing with the psychological repercussions of a radical prostatectomy, Dr. Lee, who is 56, began chemotherapy, which took his depression to a new level.

“The oncologist told me about the side effects, and I experienced them all,” he recalls. His symptoms included severe emotional swings, chronic insomnia and a “mind-numbing” feeling of hopelessness.

Guidelines to Getting Help

Still, it’s not necessary to suffer in silence. Depression is a treatable illness. But it’s often up to the patient to alert their healthcare practitioner that they are experiencing symptoms of depression.

“It can be very hard to ask for help,” says Dr. Riba. Patients may feel they are taking up the doctor’s valuable time, or they may feel confused or embarrassed about their symptoms. Drs. Riba and Strouse both recommend patients or family members discuss depression with the oncologist or primary care practitioner. They also stress the need for healthcare practitioners to help recognize depression in patients who might not speak up for themselves.

“Since depression, anxiety and mood problems can occur almost any time during and after a course of cancer, it is really important that there is a system in place for regular evaluation and treatment,” says Dr. Riba.

To help practitioners evaluate patients for symptoms of depression, the National Comprehensive Cancer Network (NCCN, www.nccn.org), a network of 18 comprehensive cancer centers, has developed systematic distress management guidelines that can be used as a screening tool. (The NCCN chose the word distress rather than depression because they felt the term carried less stigma and more accurately described patients’ emotional states.)
The guidelines include a questionnaire asking patients to measure their level of distress on a scale of one to 10. Respondents are also asked to indicate areas of their lives causing distress, such as “Practical Problems” (housing, child care, work/school), “Emotional Problems” (fears, nervousness, sadness, worry) and “Physical Problems” (fatigue, nausea, pain, sleep).

According to the NCCN guidelines, patients with a high level of anxiety or depression should be referred to a mental health professional—for example, a psychiatrist, psychologist or clinical social worker—who can more accurately assess what type of treatment is warranted.

Treating Depression

Mild to moderate depression is often responsive to talking therapy alone, notes Dr. Chochinov. For these patients, support groups, buddy systems, cancer education programs and psychotherapy can be helpful. “Such therapy is usually geared toward offering support, encouragement and hope and information to help the patient gain a sense of competence and control,” Dr. Chochinov says.

For those with moderate to severe depression, both medication and psychotherapy are usually indicated. Although a broad range of antidepressants is currently available, antidepressants vary significantly in terms of their side effects, tolerability and safety. The newer agents, such as the selective serotonin reuptake inhibitors (SSRIs), tend to have mild side effects and are often easier to take. But the benefits and risks of any depression medication need to be weighed “on a case-by-case basis,” says Dr. Chochinov, and the appropriate treatment should be decided in conjunction with one’s physician. In addition, certain herbal therapies, such as St. John’s wort, can also interfere with cancer treatments and should only be taken under a doctor’s supervision.

For Joyce Peggs, medical treatment and a supportive approach worked hand-in-hand. Being on an antidepressant gave her the psychological boost she needed to take advantage of a support group in her area.

“Once I had the antidepressant, I could do something,” she says. “Without it, I wouldn’t have followed through.”

Reaching Out to Others

Support groups can be of tremendous benefit to cancer survivors and their families, offering emotional solace and encouragement as well as a sense of community to people who might otherwise feel they were fighting a battle alone.

“Usually the depression comes from people repressing their fears and not having anywhere to talk about them,” notes Neecie Moore, PhD, a Dallas-based clinical psychologist who has led cancer support groups in her practice. “Once they have the liberty to not only talk about their fears but to be understood by someone who’s been there, there’s an amazing lifting to the depression.”

Studies have also indicated that participation in a support group can dramatically reduce depression, improve a patient’s quality of life and, in some cases, speed recovery.

“Some of the physical benefits may seem indirect, but they are direct,” says Dr. Moore, noting people often share information about adjunct treatments that could be helpful. For example, a group member might share a positive experience with nutritional therapy, inspiring another participant to explore this area of treatment.

“It’s not going to cure the cancer, but it can contribute to their physical well-being and overall health,” says Dr. Moore. “Perhaps they’re no longer experiencing nausea, or they have more energy and less fatigue.”

Other complementary therapies, such as exercise, massage, art and music, can be helpful. For Dr. Lee, relief came from working out at the gym.

“I’m one of those unfortunate people who can’t take antidepressants, so I had to learn to deal with the depression, the mood swings and the unbelievable hot flashes,” he says.

To counteract his symptoms, Dr. Lee continued to exercise, stopping by the health club several times a week. “There’s nothing better than running three to five miles and pushing some iron. Exercise releases endorphins, which are natural mood elevators.”

A Positive Outlook

Cancer is a life-altering experience that brings with it both physical and emotional challenges. But a cancer diagnosis does not have to result in depression, and symptoms of distress should never be ignored. Myriad treatment options exist to help manage depression at all levels, offering cancer patients a renewed sense of hope.

“The evidence is starting to mount that treating depressive symptomology or clinical depression is not just good for the patient’s mental health; it can make a difference in terms of the success of the medical treatment,” notes Kirk Warren Brown, PhD, visiting assistant professor in the Department of Clinical and Social Sciences at the University of Rochester in New York, whose recent research has explored the link between depression and longevity in cancer patients.

Dr. Brown and researchers at the University of Rochester found that symptoms of depression may be the most consistent psychological predictor of shortened survival in cancer patients. Surprisingly, however, the researchers found no correlation between either the type of diagnosis or the stage of cancer and the patients’ levels of depression.

“It could be expected that if someone got a diagnosis of a very severe or aggressive cancer versus a less severe and more treatable cancer, there would be a correlation with their level of depression,” notes Dr. Brown. However, after controlling for physiological predictors of survival time, the symptoms of psychological distress still emerged as the best indicator of a cancer patient’s life expectancy.

“We also looked at whether depressive symptoms were a side effect of the type of medical treatment people were getting—whether it was a systemic treatment, like chemotherapy, or a local treatment, like surgery—and again, we found no relationship [with survival time],” Dr. Brown says.

Perhaps most importantly, depression can have a dramatic impact on a patient’s quality of life, regardless of the cancer diagnosis. “It’s like a smothering blanket has been lifted from me,” says Peggs. Getting treatment for depression “has helped me stay in the moment and enjoy today.”