The Down Low

Cancer is not a naturally happy subject and one of its unhappy psychological side effects is depression. Roughly 50% of cancer patients suffer from some form of diagnosable psychiatric disorder during the course of their illness. Depression affects around 15 – 25% of cancer patients and major depression affects about 25% of those who have cancer. Rather understandable figures when one considers that one is dealing with a chronic disease that is in many instances still terminal. Even when it is not terminal it is painful and the treatment is hell. It is surprising that the figures for depression aren’t higher.

Men and women with cancer are equally affected by depression. Major depression has the following symptoms, of which a number should be present for at least 2 weeks in order for a psychiatric diagnosis to be made: 1) a depressed mood for most of the day 2) loss of pleasure and interest in favoured activities 3) change in appetite either increase or decrease 4) change in sleeping patterns, either an increase or decrease in the amount of sleep you need 5) constant thoughts of death or suicide 6) lethargy or apathy towards things in general 7) problems concentrating 8) sluggishness or agitation (fidgety) 9) feelings of worthlessness or inappropriate guilt 10) feeling hopeless or helpless 11) tiredness and a decrease in energy.

A proper diagnosis of depression is difficult to make in cancer patients as the symptoms often overlap with the symptoms of cancer or with the side effects of the various medications. The symptoms that are the most telling when it comes to a diagnosis of true depression are guilt, worthlessness, hopelessness, and thoughts of suicide and loss of pleasure. Another important point to consider is whether or not the person suffered from depression before the cancer. If there is a history of depression then it is more than likely that the symptoms will point to a recurrence of depression rather than anything else, especially if the symptoms of depression begin to present themselves fairly early on in the illness.

There are cancer related risk factors for depression and non-cancer related risk factors.
The cancer related risk factors include:
1) depression at the time of diagnosis 2) poor pain management 3) cancer at an advanced stage 4) increased physical impairment or pain 5) pancreatic cancer 6) treatment with some anticancer drugs 7) being unmarried and having head and neck cancer, it seems odd that those two are linked. You have to be unmarried and have head and neck cancer, it’s not enough to have head and neck cancer alone, you must also be unmarried for depression to set in. Very strange the human brain.

The non-cancer related risk factors include
1) history of depression 2) lack of family support 3) other life events that cause stress 4) family history of depression or suicide 5) previous suicide attempts 6) history of alcoholism or drug abuse 7) having many illnesses at the same time that produce symptoms of depression e.g. a stroke or heart attack.

Suicide ideation is frightening for all concerned, although possibly more for the family than for the individual concerned. The individual concerned has usually resigned him or herself to death and is often unafraid at this point. It is the family that is terrified that the individual will do something irrevocable. Even suicidal talk is frightening to the family who may hear statements that range from offhand comments like “One more blood test and I swear I’ll shoot myself in the eye” to more despairing statements that reflect how the individual truly feels about the situation at hand such as “This disease is pulling our family apart, it would be better for me to kill myself now while there’s still something left to save.”

It is important to determine how serious the threat of suicide is. If the person is deemed serious and determined then he or she should be referred to a psychiatrist or a psychologist for careful evaluation. The risk of suicide increases with the detail of the plan. A lethal suicide plan is more likely to be carried out if the means chosen are available to the individual, the attempt can’t be stopped once it has begun and help isn’t available. Risk factors should be speedily identified and treated. Hopelessness is a better predictor for suicide than depression and should be watched for very carefully. Although it’s difficult to assess and allay hopelessness in someone who has advanced cancer with no hope of a cure it is nevertheless still important to determine the basic reasons for hopelessness. Some may be related to the cancer and its symptoms, others may relate to the fear of a painful death and still others to fears of abandonment.

There is a perception that talking about suicide will somehow cause the person contemplating it to hasten the act. This is false. Talking about suicide shows your concern and allows the person concerned to share his or her feelings and fears around the issue, thus returning a sense of control to him or her. It may be necessary to take a crisis intervention orientated treatment approach, which should involve the patient’s entire support system. Contributing cancer symptoms e.g. pain should be aggressively controlled and depression, psychosis, anxiety and any underlying causes of delirium should be treated, either in hospital or at home. Suicidal cancer patients may need to be hospitalised in a psychiatric ward, but this is not usually necessary.

Of the 25% of all cancer patients who suffer from depression, only about 16% will get medication for their depression. The kind of antidepressant will depend on a variety of things including the patient’s symptoms, the potential side effects of the antidepressant and the individual’s medical problems as well as previous response to antidepressants. Most antidepressants take 3-6 weeks to begin working and this must also be taken into account. Therapy can be used as an alternative treatment to medication or it can be used in conjunction with medication. Some of the specific goals of therapy include: assisting cancer patients and their families by answering questions about the illness and its treatment, explaining information, correcting misunderstandings, giving reassurance regarding the situation and exploring how the diagnosis relates to previous experiences with cancer.

It also assists with problem solving, aims to improve the patient’s coping skills and help the patient and family develop additional coping skills, explore other areas of stress and encourage family members to support one another and concerns with each other.
It ensures that the patient and family understand that support will continue when the treatment changes from trying to cure the cancer to relieving the symptoms of cancer.

Cancer support groups have been found to be helpful in dealing with depression in cancer patients, especially in teenage patients. They improve mood, encourage the development of coping skills, improve the quality if life and improve immune response. Support groups can be found through many community resources including the social work departments in medical centres and hospitals.

There is one nice thing about depression; it can be beaten. The only thing is that you don’t know it at the time. At the time you don’t think that the suffocating blackness will ever go away. You don’t think that things will be better ever again and who cares if the sun comes out tomorrow, you’ll smack the first person who says that to you in the eye. All you can think about is blackness and hopelessness and how bad everything is and how bad it is because of you and everything is your fault. Its not, however, your fault that thoughts of death and disfigurement bring you a sense of peace yet suddenly people have you on suicide watch, lock all you pills away and make you eat with a plastic spoon, which they take away from you as soon as you’ve finished doing battle with it. Therapy works, medication works, they work very well together. There is no need to be embarrassed or to feel ashamed by the fact that you have a psychological disorder. You have no idea how many others share your pain. All you need to do is say “I’m on antidepressants” to hear how many of your friends, you would never have guessed, are on antidepressants too. The nice thing about depression is that it can be beaten, you have to fight like hell and you have to really want to get out but it can be done. And then one day you’ll be the person enjoying the sun and looking forward to tomorrow because it’ll come out again.

Recommended sites:
http://www.cancernews.com/articles/cancer&depression.htm
http://www.cancer.gov/cancertopics/pdq/supportivecare/depression/Patient/page11

Sandra wrote this article for the online marketers Tell Her UK cervical cancer one of the leading cervical cancer websites on the net

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