Depression and Cancer
Depression. The term is used loosely and frequently in normal life. People say: "I am so depressed" when the sun does not shine for the 4th consecutive day or, as happened last week, it snows for the 10th consecutive week-end. Since this is common language, we all understand these these remarks don't mean that someone needs to head directly to a psychiatrist for a prescription for anti-depressants. But how does the word get used in Cancer World and what does it really mean?
First, a quick lesson about the clinical/medical meanings of depression. The DSM-V is the bible from the American Psychiatric Association that carefully lists and defines all "mental disorders". These range from psychosis and schizophrenia to normal grief during bereavement. For depression, there are two major groupings: mood disorders that are very common reactions to life's difficulties and major depressions that are a form of mental illness that respond well to medications. In my experience, virtually everyone who is diagnosed with cancer could also be diagnosed with a mood disorder. The most common in my practice include a generalized mood disorder with both depressed and anxious feelings (pretty much applies to everyone with cancer) and mood disorders due to X (a medical condition). Major depressions include bipolar illness, major depressions, and cyclothymic disorders.
Around half of patients diagnosed with cancer experience an expectable reaction when facing life-threatening illness. Whether shared with family and friends or kept in private, many fears emerge: dying, being in pain, becoming dependent on family and the health care system, and being unable to carry on life’s usual tasks. As the specifics of the cancer are teased out and treatment routines are established, distress often becomes self-limited, with peaks at certain predictable times of change in treatment modality (surgery, chemotherapy, and radiation therapy) or treatment response. These reactions could all be classified as mood disorders. Strong social support, a reliable faith system, and knowledge serve as buffers during this time of crisis. Individual emotional resiliency helps bolster coping.
About 15-20% of cancer patients experience a major depressive disorder. This is approximately twice the incidence of depression in the general population. There are people who are particularly vulnerable, including those with a personal or family history of depression and those diagnosed with certain especially lethal cancers.
When assessing depression in people with cancer, it is important to remember that some of the side effects of cancer and its treatments are similar to symptoms of major depression and dysthymic depression (e.g, , fatigue, lack of energy, sexual disturbance, poor concentration, poor appetite, loss of interest in usual activities, and insomnia or hypersomnia). Some of these symptoms can be side effects of chemotherapy treatments, so it is important to check out that possibility. If a patient says that s/he has nothing to look forward to and seems affectively flat, it is especially important to listen carefully and consider depression. Even those who are quite ill usually have events to anticipate.
As you can discern from this brief explanation, it can be very tough to tease out what is major depression and what is a common, although painful, reaction to very difficult life circumstances. My long experience has taught me that patients usually, although not always, know the difference. Anytime that the patient is worried about him/herself or my own instincts suggest that we may be dealing with clinical/major depression, I set up a consultation with a psychiatrist who is experienced with cancer. I have learned the hard way that psychiatrists without this special expertise may not be helpful. Long ago, I asked a psychiatrist to meet with a man who was medically and mentally suffering. He had advanced cancer, but he was also depressed. When the psychiatrist saw him, his only comment was: "I would be depressed, too, if I were that ill." Not helpful!
It was heartening to come across this article and information about a study from Scotland that was designed to actively intervene early in a cancer patient's experience. Early support makes a difference in managing or preventing depression. Here is the start and a link:
Paying Attention to Depression
Psychiatrist Michael Sharpe suggests a new approach to identifying and treating depression in cancer patients
By Marci A. Landsmann
In 2000, Michael Sharpe, a psychiatrist and senior lecturer at the University of Edinburgh Cancer Research UK Centre in Scotland, was interviewing cancer survivors to confirm a diagnosis of clinical depression for a research study, when he noticed a disturbing trend. “It seemed to me that while they had very good cancer treatment, the job was often not finished,” Sharpe recalls. “Many of them came through their cancer treatments, and one notably said to me, ‘I went through that treatment and they say I’m cured, but I wish I’d died.’ ”
Clinical depression, characterized by a persistent lack of interest in all activities or a feeling of hopelessness that lasts two weeks or more, affects an estimated 10 percent of cancer survivors, which is two times the rate in the general population, according to Sharpe, who is now a professor of psychological medicine at the University of Oxford in England. Symptoms of depression are often overlooked or dismissed, he says. “Even if patients and doctors pick up that the patient is feeling very low, they see this as normal for having cancer,” Sharpe says. “Rather than thinking, ‘I should treat that,’ they say, ‘Well, they’ve got cancer—that’s what you’d expect.’ ”