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NCI/PDQ^® Patients: Depression (PDQ®)

National Cancer Institute
Ultima Vez Modificado: 12 de diciembre del 2012

TABLE OF CONTENTS

• General Information About Depression

• Diagnosis of Depression

• Treatment of Depression

• Suicide Risk in Patients with Cancer

• Palliative Sedation

• Depression in Children

• To Learn More About Depression

• Changes to This Summary (12/12/2012)

• Questions or Comments About This Summary

• Get More Information From NCI

• About PDQ®

General Information About Depression

Depression is different from normal sadness.

Depression is not simply feeling sad. Depression is a disorder with specific symptoms that can be diagnosed and treated. About one-fourth of cancer patients become depressed. The numbers of men and women affected are about the same.

A person diagnosed with cancer faces many stressful issues. These may include:

• Fear of death.
• Changes in life plans.
• Changes in body image and self-esteem.
• Changes in day to day living.
• Money and legal concerns.

Sadness and grief are normal reactions to a cancer diagnosis. A person with cancer may also have:

• Feelings of disbelief, denial, or despair.
• Trouble sleeping.
• Loss of appetite.
• Anxiety or worry about the future.

Not everyone who is diagnosed with cancer reacts in the same way. Some cancer patients may not have depression or anxiety, while others may have high levels of both.

Signs that you have adjusted to the cancer diagnosis and treatment include being able to stay active in daily life and continue in your roles such as:

• Spouse.
• Parent.
• Employee.

This summary is mainly about depression in adults with cancer. There is a section at the end of the summary about depression in children with cancer.

Some cancer patients may have a higher risk of depression.

There are known risk factors for depression after a cancer diagnosis. Factors that increase the risk of depression are not always related to the cancer.

• Risk factors related to cancer

  Risk factors related to cancer that may cause depression include the following:

  • Learning you have cancer when you are already depressed for other reasons.
  • Having cancer pain that is not well controlled.
  • Having advanced cancer.
  • Being physically weakened by the cancer.
  • Being unmarried (for certain types of cancer).
  • Having pancreatic cancer.
  • Taking certain medicines, such as:
    • Corticosteroids.
    • Procarbazine.
    • L-asparaginase.
    • Interferon alfa.
    • Interleukin-2.
    • Amphotericin B.

• Risk factors not related to cancer

  Risk factors not related to cancer that may cause depression include the following:

  • A personal or family history of depression or suicide.
  • A personal history of alcoholism or drug abuse.
  • A personal history of mental problems.
  • A weak social support system (not being married, having few family members or friends, having a job where you work alone).
  • Stress caused by life events other than the cancer.
  • Health problems that are known to cause depression (such as stroke or heart attack).

There are many medical conditions that can cause depression.

Medical conditions that may cause depression include the following:

• Pain that doesn't go away with treatment.
• Anemia.
• Fever.
• Abnormal levels of calcium, sodium, or potassium in the blood.
• Not enough vitamin B12 or folate in your diet.
• Too much or too little thyroid hormone.
• Too little adrenal hormone.
• Side effects of certain medicines.

Depression and anxiety are common in patients whose cancer is advanced and can no longer be treated.

Patients whose cancer can no longer be treated often feel depressed and anxious. These feelings can lower the quality of life. Terminally ill patients who are depressed report being troubled about:

• Symptoms.
• Relationships.
• Beliefs about life.

Depressed terminally ill patients feel they are "being a burden" even when they don't depend very much on others.

Family members also have a risk of depression.

Anxiety and depression are also common in family members caring for loved ones with cancer. Children are affected when a parent with cancer is depressed and may have emotional and behavioral problems themselves.

Good communication helps. Family members who talk about feelings and solve problems are more likely to have lower levels of anxiety and depression.

Diagnosis of Depression

Major depression has specific symptoms that last longer than two weeks.

It's normal to feel sad after learning you have cancer, but a diagnosis of depression depends on more than being unhappy. Symptoms of depression include the following:

• Feeling sad most of the time.
• Loss of pleasure and interest in activities you used to enjoy.
• Changes in eating and sleeping habits.
• Nervousness.
• Slow physical and mental responses.
• Unexplained tiredness.
• Feeling worthless.
• Feeling guilt for no reason.
• Not being able to pay attention.
• Frequent thoughts of death or suicide.

Your doctor will talk with you to find out if you have symptoms of depression.

Your doctor wants to know how you are feeling and may want to discuss the following:

• The normal feelings cancer patients have. Talking with your doctor about this may help you see if your feelings are normal sadness or more serious.
• Your moods. You may be asked to rate your mood on a scale.
• How long the symptoms have lasted.
• How the symptoms affect your daily life, such as your relationships, your work, and your ability to enjoy your usual activities.
• All the medicines you are taking and other treatments you are receiving. Sometimes, side effects of medicines or the cancer can look like symptoms of depression. This is more likely during active cancer treatment or advanced cancer.

This information will help you and your doctor find out if you are feeling normal sadness or have a depressive disorder.

Checking for depression may be repeated at times when stress increases, such as when cancer gets worse or comes back after treatment.

Physical exams, mental exams, and lab tests are used to diagnose depression.

In addition to talking with you, your doctor may do the following to check for depression:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of your health habits, past illnesses including depression, and treatments will also be taken. A physical exam can help rule out a physical condition that may be causing your symptoms.
• Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time. Lab tests are done to rule out a medical condition that may be causing symptoms of depression.
• Mental status exam: An exam done to get a general idea of your mental state by checking the following:
  • How you look and act.
  • Your mood.
  • Your speech.
  • Your memory.
  • How well you pay attention and understand simple concepts.

Treatment of Depression

The decision to treat depression depends on how long it has lasted and how much it affects your life.

If you cannot adjust to the cancer diagnosis after a long time and you have lost interest in your usual activities, you may have depression that needs to be treated. Treatment of depression may include medicines, talk therapy, or both.

Treatment of major depression usually includes medicine.

It's important to use antidepressants only under the care of a doctor.

Antidepressants help relieve depression and its symptoms. When you are taking antidepressants, it's important that they are used under the care of a doctor. You may be treated with a number of medicines during your cancer care. Some anticancer medicines may not mix safely with certain antidepressants or with certain foods, herbals, or nutritional supplements. It's important to tell your healthcare providers about all the medicines, herbals, and nutritional supplements you are taking, including medicines used as patches on the skin. This can help prevent unwanted reactions.

Many antidepressants take from 3 to 6 weeks to work. Usually, you begin at a low dose that is slowly increased to find the right dose for you. This helps to avoid side effects.

Check with your doctor before you stop taking an antidepressant. You may need to slowly reduce the dose of some types of antidepressants. This is to prevent side effects you may have if you suddenly stop taking the medicine.

There are different types of antidepressants.

Most antidepressants help treat depression by changing the levels of chemicals called neurotransmitters in the brain. Nerves use these chemicals to send messages to one another. Increasing the amount of these chemicals helps to improve mood. The different types of antidepressants act on these chemicals in different ways and have different side effects.

Three types of antidepressants are commonly used to treat depression in patients with cancer:

• SSRIs (selective serotonin reuptake inhibitors): Medicines that increase the brain chemical serotonin.
• Tricyclic antidepressants: Medicines that increase the brain chemicals serotonin and norepinephrine.
• Central nervous system (CNS) stimulants: Medicines that increase the brain chemicals dopamine and norepinephrine.

There are other types of antidepressants that may be used:

• Bupropion.
• Venlafaxine.
• Trazodone.
• Mirtazapine.
• Benzodiazepines.
• Psychostimulants.
• Monoamine oxidase inhibitors (MAOIs).

The antidepressant that is best for you depends on the following:

• Your symptoms.
• Your medical problems.
• Possible side effects of the antidepressant.
• The form of medicine you are able to take (such as a pill or a liquid).
• Other medicines you are taking.
• How you responded to antidepressants in the past.

St. John's wort may change the way some of your other medicines work.

St. John's wort (Hypericum perforatum) is an herbal product sold as an over-the-counter treatment for depression. St. John's wort has not been proven to be better than standard antidepressant medicines. Many studies have been done to compare St. John's wort with antidepressants, placebo (inactive) medicines, or both, and have shown mixed results.

Be sure to talk with your doctor before taking St. John's wort. It may change the way some of your other medicines work, including anticancer medicines. Also, there are no standards for companies that make St. John's wort, so the amount of active ingredient may be different in each brand.

Counseling or talk therapy helps some cancer patients with depression.

Your doctor may suggest you see a psychologist or psychiatrist for the following reasons:

• Your depression is getting worse.
• The depression keeps you from continuing with your cancer treatment.
• The antidepressants you are taking are causing unwanted side effects.
• Your symptoms have been treated for 2 to 4 weeks and are not getting better.

Most counseling or talk therapy programs for depression are offered in both individual and small-group settings. Some of these include:

• Crisis intervention.
• Psychotherapy.
• Cognitive-behavioral therapy.

More than one type of therapy program may be right for you. Therapy programs for cancer patients teach about the following:

• Cancer and its treatment.
• Relaxation skills and ways to lower stress.
• Coping and problem-solving skills.
• Getting rid of negative thoughts.
• Social support.

Patients in therapy often form a close personal bond with an understanding health care provider. Talking with a clergy member may also be helpful for some people.

Suicide Risk in Patients with Cancer

It's common for cancer patients to feel hopeless at times.

Cancer patients sometimes feel hopeless. Although few cancer patients are reported to die by suicide, talk with your doctor if you feel hopeless or have thoughts of suicide. There are ways your doctor can help you. Getting treatment for major depression has been shown to lower the risk of suicide in cancer patients.

Risk factors for suicide may be related to the cancer or other conditions.

General risk factors for suicide include the following:

• A history of mental problems, especially those that cause you to act without thinking.
• A family history of suicide.
• A history of suicide attempts.
• Depression or feeling hopeless.
• Drug or alcohol abuse.
• Recent death of a friend or spouse.
• Few friends or little family support.

Risk factors that are related to cancer include the following:

• A diagnosis of oral, throat, or lung cancer.
• Advanced stage cancer and poor prognosis.
• Confusion or being unable to think clearly.
• Pain that is not relieved with treatment.
• Physical changes such as the following:
  • Being unable to walk and move around on your own.
  • Loss of bowel and bladder control.
  • Loss of a limb (amputation).
  • Loss of eyesight or hearing.
  • Paralysis.
  • Being unable to eat or swallow.
  • Extreme tiredness.

An assessment is done to find the reasons for hopeless feelings or thoughts of suicide.

Talking about thoughts of suicide with your doctor gives you a chance to describe your feelings and fears, and may help you feel more in control. Your doctor will try to find out what is causing your hopeless feelings, such as:

• Symptoms that are not well controlled.
• Fear of having a painful death.
• Fear of being alone during your cancer experience.

You can find out what may be done to help relieve your emotional and physical pain.

Controlling symptoms caused by cancer and cancer treatment is an important goal in preventing suicide.

Having constant discomfort or pain can cause you to feel desperate. Keeping pain and other symptoms under control will help to:

• Relieve distress.
• Make you feel more comfortable.
• Prevent thoughts of suicide.

Treatment may include antidepressants. Some antidepressants take a few weeks to work. The doctor may prescribe other medicines that work quickly to relieve distress until the antidepressant begins to work. Patients usually are given only a small number of doses at a time. For your safety, it's important to have frequent contact with a health care professional and avoid being alone until your symptoms are controlled. Your health care team can help you find social support.

Losing a loved one to suicide is especially hard for the family and friends.

The shock and grief felt after the loss of a loved one to suicide is very difficult. Family members and others who loved the patient may feel like they have been left or rejected. They may feel guilty or angry or they may feel responsible for the suicide. Talking with a professional or a support group can be very helpful for family members and others who loved the patient. Support groups can:

• Offer friendship.
• Give you time to talk about feelings.
• Help you find ways to cope with the loss.

It may help just to know that these feelings are felt by others.

Palliative Sedation

Sedation may be considered for comfort.

Patients with advanced cancer or near the end of life may have:

• A lot of emotional distress and physical pain.
• Difficult and painful breathing.
• Confusion (especially when body systems begin to fail).

Sedation can be given to ease these conditions. This is called palliative sedation. Deciding to use palliative sedation may be difficult for the family as well as the patient. The patient and family can get support from the health care team and mental health professionals when palliative sedation is used.

Choices about care and treatment at the end of life should be made while you are still able to make them.

Your thoughts and feelings about end-of-life sedation may depend on your own culture and beliefs. Some patients who become anxious facing 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 you to tell family members and health care providers of your wishes about sedation at the end of life. When you make your wishes about sedation known ahead of time, doctors and family members can be sure they're doing what you would want.

Depression in Children

Most children cope well with cancer. A small number of children may have:

• Depression.
• Anxiety.
• Trouble sleeping.
• Problems getting along with family or friends.
• Problems staying on treatment.

These problems can affect the child's cancer treatment and enjoyment of life. Children with severe late effects from cancer treatment may be more likely to have symptoms of depression. A mental health specialist can help children with depression.

Assessment for depression includes looking at the child's symptoms, behavior, and health history.

As in adults, normal sadness in children is not depression. Depression lasts longer and has specific symptoms. The doctor may assess the child for depression if a behavior problem goes on for a long time. To assess for depression, the doctor will need the following information about the child:

• Home life with family.
• How the child faces illness and treatment.
• Age and stage of development.
• Past illnesses and how the child responded to them.
• Sense of self-worth.
• Behavior, as seen by the parents, teachers, or others.

The doctor will talk with the child and may use a set of questions or a checklist that helps to diagnose depression in children.

A diagnosis of depression depends on the symptoms and how long they have lasted.

Children who are depressed have an unhappy mood and at least 4 of the following symptoms every day for 2 weeks or longer:

• Appetite changes.
• Not sleeping or sleeping too much.
• Being unable to relax and be still (such as pacing, fidgeting, and pulling at clothing).
• Frequent crying.
• Loss of interest or pleasure in usual activities.
• Lack of emotion in children younger than 6 years.
• Feeling very tired or having little energy.
• Feelings of worthlessness, blame, or guilt.
• Unable to think or pay attention and frequent daydreaming.
• Refusing to go to school.
• Trouble learning and getting along with others.
• Aggressive behavior.
• Anger towards self, parents, and teachers.
• Frequent thoughts of death or suicide.

Treatment may be therapy or medicine.

Talk therapy is the main treatment for depression in children.

Individual and group talk therapy are the main treatments for depression in children. This may include play therapy for younger children. Therapy will help the child cope with feelings of depression and also understand the cancer and its treatment.

Medicines for depression may be used with care.

The doctor may prescribe antidepressants for children with severe depression and anxiety. Children taking antidepressants must be watched closely.SSRIs (selective serotonin reuptake inhibitors) are a type of antidepressant that usually have few side effects. However, in some children, teenagers, and young adults, SSRIs make depression worse or cause thoughts of suicide. The Food and Drug Administration has warned that patients younger than age 25 who are taking SSRIs should be watched closely for signs that the depression is getting worse and for suicidal thinking or behavior. This is especially important during the first 4 to 8 weeks of treatment.

See the section on Depression and Suicide in the PDQ® summary on Pediatric Supportive Care for more information.

To Learn More About Depression

For more information from the National Cancer Institute about depression, see the following:

• Adjustment to Cancer: Anxiety and Distress
• Coping with Advanced Cancer: Coping With Your Feelings
• Facing Forward: Life After Cancer Treatment; Your Feelings
• How To Find Resources in Your Own Community If You Have Cancer

Changes to This Summary (12/12/2012)

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.

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If you have questions or comments about this summary, please send them to Cancer.gov through the Web site's Contact Form. We can respond only to email messages written in English.

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A clinical trial is a study to answer a scientific question, such as whether one method of treating symptoms is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. Some patients have symptoms caused by cancer treatment or by the cancer itself. During supportive care clinical trials, information is collected about how well new ways to treat symptoms of cancer work. The trials also study side effects of treatment and problems that come up during or after treatment. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients who have symptoms related to cancer treatment may want to think about taking part in a clinical trial.

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