What Is Depression in Cancer? Depression Symptoms and Treatment

Depression is a mental disorder affecting more than 3oo million people worldwide and causing the greatest loss of functioning among all illnesses, physical and psychological. Depression rates of % 5 in the general population rise to %15-20 among patients with cancer and even %25-30 among those with advanced disease. This article discusses depression, also called depressive disorder, experienced by almost one in every 4-5 of our patients, which adversely affects treatment and its outcomes and reduces quality of life.

What is depression?

We all sometimes feel sad, helpless or discouraged in response to life events. Sometimes the problem disappears and everything returns to normal; sometimes we adapt to new circumstances and learn to cope with these feelings. Our previous two articles discussed the wide range of emotions that may be experienced during cancer. Depression, however, involves far more than feeling bad for a while. Diagnostic systems define it as a cluster of symptoms lasting at least two weeks and sufficiently severe and intense to disrupt a person’s life and functioning .

What are the symptoms of depression?

1. Feeling low, unhappy, sad, distressed, tense or irritable
2. Loss of enjoyment in previously enjoyable activities, unwillingness to do them and reduced motivation
3. Tiredness and fatigue
4. Sleep disturbances: difficulty falling asleep, fragmented sleep, or waking early against one’s wishes and being unable to fall asleep again. Sometimes the opposite occurs, with increased sleep duration. Someone normally satisfied with 7 hours may sleep much longer yet still feel sleepy. 
5. Appetite changes: usually reduced appetite and weight loss, but sometimes a marked increase in appetite
6. Problems with attention and concentration, forgetfulness
7. Reduced self-confidence
8. Pessimism, hopelessness, worthlessness, inadequacy, incompetence and guilt
9. Life seeming meaningless, thoughts of death and even suicide attempts

Among the symptoms listed above:

• If you have any 4-5 of the other symptoms, with one or two of the first three definitely present*, 
• If these symptoms have continued for at least two weeks,
• If they are not directly caused by a physical illness—for example, an underactive thyroid (hypothyroidism) can mimic depression symptoms, but that condition is not diagnosed as depression; therefore, before confirming the diagnosis, certain diagnostic tests are performed)
• If they are not due to the direct effects of illegal substance or alcohol use,
• If all these symptoms impair your functioning—for example, reduced self-care or inability to fulfill personal responsibilities—the diagnosis is DEPRESSION.

* The American diagnostic system requires, from 9 symptoms, 5, with one of the first two definitely present, while the European system requires at least 4 symptoms overall, including two of the first three. Therefore, psychiatrists diagnose depression by examining the patient’s individual clinical situation in detail rather than merely counting symptoms. . .

Depression in cancer

Diagnosing depression in cancer is difficult. Poor appetite and weight loss, fatigue and tiredness, insomnia, and attention and concentration problems can often result from cancer itself or treatment. If we cannot distinguish their cause, we will inevitably label every unhappy patient as depressed, which is incorrect. Scientific studies therefore emphasize that, when diagnosing depression in patients with cancer, factors such as pessimism, hopelessness, inadequacy, guilt, reduced self-confidence and feelings of dependency on caregivers may be more decisive. Delaying treatment, incomplete adherence and outright treatment refusal are also important situations that should raise suspicion of depression.

Similarly, depression may cause many physical complaints, including pain—particularly headaches—and gastrointestinal symptoms. Head, neck and back pain, stomach burning, nausea, altered bowel habits, migrating sensations of stinging, burning or pins and needles, dizziness and lightheadedness may accompany it. Recognizing depression in people with physical illnesses therefore requires expertise.

What causes depression in cancer?

In general, depression arises from deficiencies or imbalances in certain chemicals in brain regions responsible for emotional state, motivation, sleep, appetite and attention. This chemical imbalance in the brain does not have a single cause; it usually results from several influences acting together. Factors causing these chemical changes and depression symptoms include the following.

Biological factors

Scientific studies show that the following biological factors predispose some patients to depression or directly cause it.

• Cancer location: Depression is more common in patients with head-and-neck, pancreatic, lung or breast cancer and brain tumors.
• Cancer stage: Depression rates have been observed to reach %35 in advanced cancer.
• Direct depression-inducing effects of certain drugs: Corticosteroids, procarbazine, L-asparaginase, Vinkristie, vinblastine, interferon-alpha, interleukin 2, docetaxel, paclitaxel, Ampfotericin B, and prolonged high-dose opioid painkiller use
• Side effects of certain treatments: A marked reduction in red blood cells (anemia), hormonal imbalances such as hypothyroidism and adrenal insufficiency
• Long-term inadequate and unbalanced nutrition or vitamin deficiencies due to nausea and vomiting if not replaced—for example, folic acid, vitamin B and vitamin D deficiencies—and mineral imbalances involving calcium, sodium and potassium salts
• Pain that does not respond to painkillers, pain and prolonged sleep disturbances can predispose people to depression.
• Coexisting diseases (diabetes, a previous stroke and similar chronic conditions)

Psychosocial factors

Many psychological and social factors can also alter brain chemicals over time and cause depression. Major triggers include:

• Receiving the diagnosis, fear of death and existential conflicts
• Learning that cancer is advanced or terminal
• Failure to respond to treatment or recurrence
• Changes in social identity and roles, financial difficulties and legal challenges
• An inadequate social support system
• Changes in appearance caused by cancer or treatment, altered body image, loss of self-confidence and effects on social and sexual life, including breast surgery, head, neck or facial surgery, genital surgery and radiotherapy sequelae
• Uncertainty and lack of control over the future

Personal factors

Personal factors strongly influence which mental illness develops, in whom and with what severity. Important factors include age, sex, education, marital status, having children, occupation, past losses, family cancer history, previous mental illness, personality and coping characteristics, attachment styles, social support and belief systems. Many factors may predispose someone to depression: being young; being unmarried in certain cancers; having or not having children when disease or treatment affects fertility; being unable to work as the household breadwinner; or a history of depression...

Why Is Recognizing Depression in Cancer Important?

Saying “Sadness and grief are part of this illness; we must accept it and move on” may sound like mature acceptance. But what can happen if the symptoms described above go unnoticed and depression is neither diagnosed nor treated?

• Unrecognized severe depression can lead to suicidal thoughts and attempts. Studies show that the period of 3-5 months after diagnosis carries a higher suicide risk than other periods. Overall, the suicide rate among patients with cancer is two times that of the general population.
• It reduces quality of life. Living cannot be understood merely as the continuation of bodily functions. Beyond breathing, it means meeting and satisfying psychological needs. As social beings, we need to communicate with loved ones, fulfill family roles and responsibilities, maintain a sexual life, participate in work, desire things, enjoy food, expend effort and energy, produce and achieve things, realize dreams, earn money, spend as we wish and practice our beliefs... Being able to do these and dozens of other meaningful things not listed here describes quality of life . Unfortunately, when depression is added to life already impaired by cancer and its treatments, these elements are adversely affected and quality of life declines further. 
• Treatment-related difficulty making decisions, regarding recommended treatments with a very high likelihood of benefit, a tendency to refuse them
• Difficulty adhering to treatments, a tendency to stop treatment prematurely, with the treatment received, services provided or relatives’ care, dissatisfaction
• Increased unexplained physical complaints and their severity; pain, burning, numbness, nausea and gastrointestinal changes
• More investigations requested to identify these complaints and more medication used to relieve them
• Reduced self-care and life-management abilities, motivational difficulties such as not quitting smoking, not performing recommended exercises or not paying attention to diet
• Increased depression among caregivers
• Because of the factors above, reduced treatment success and lower survival rates..

Treating depression in patients with cancer

Although depression is very common, fewer than half of patients—and in some regions only %10—can access psychological or psychiatric treatment. This may reflect poor recognition of symptoms, a tendency to view seeking help as inadequacy, reluctance to seek help because of fear of being labeled “mentally ill,” or a lack of adequately trained doctors or psychologists. Yet treatment success is almost the rule among patients with depression who cooperate with treatment. Response rates are high.

Recognizing symptoms is the first step in depression during cancer. Next comes investigating their causes. Where do these depressive complaints originate? Are they a direct effect of cancer or side effects of treatment? Are they caused by inability to grieve actual or anticipated losses, changing social roles or financial hardship? The circumstances causing psychological distress differ for each person. Every treatment must therefore be planned individually.

In mild depression, psychiatric medication is often not the first choice, primarily because medication is much less effective in mild depression than in moderate or severe depression. In mild depression:

1. Patients and families can receive education about the cancer journey, possible situations and their management, namely psychoeducation . Brief educational sessions by mental health professionals and nurses to support self-management of the disease and side effects contribute positively to both patients’ and families’ mental health. 
2. To help identify patients’ problems and strengthen coping strategies, supportive psychotherapies may be used, as can therapies whose effectiveness in reducing depression and anxiety symptoms and improving quality of life has been demonstrated in many studies: cognitive behavioral therapies .
3. To help restore the whole family’s changing routines, identify members’ psychological states and discover the most suitable coping and problem-solving approaches, family counseling and family therapies are highly effective. When sexual problems arise for any reason, sex therapies can be beneficial.
4. To meet others experiencing similar difficulties, express emotions, learn coping methods and experience a sense of belonging, group psychotherapies or patient support group meetings can be organized.

In addition to the therapies above requiring specialist training, mild depression can be addressed through:

1. Breathing and relaxation exercises, mind–body techniques, meditation and yoga
2. Regular light exercise
3. Music and art (occupational) therapies
4. Religious and spiritual coping strategies also have a place in treatment. All are techniques whose effectiveness has been demonstrated in scientific studies.

For moderate and severe depression, medication is considered first, supported by therapies. Antidepressants are the preferred drugs for treating depression. Sometimes anxiety-relieving medications and drugs regulating sleep and energy are also used. Patients already taking many medications are often apprehensive about psychiatric drugs and refuse them. Psychiatric medication use in cancer will therefore be discussed in greater detail separately. However, because myths about depression medications abound, I would like to finish by addressing a few points.

Myth 1: Antidepressants are ineffective!

Debate repeatedly arises over claims that depression medications are ineffective and do not work. However, we can clearly state that antidepressant effectiveness is scientifically proven. They should never be viewed as a morale boost, happiness pill, substance that numbs people into forgetting their troubles, or habit-forming medication. Their maximum benefit is achieved particularly in moderate and severe depression. Patients with cancer may sometimes receive low doses for certain complaints even without depression, such as insomnia, nausea or appetite loss...

Myth 2: Antidepressants have lots of side effects!

Every medication has side effects. After assessment, however, physicians initiate psychiatric medication by weighing benefits and harms while considering both physical and psychological health. There are antidepressants that promote sleep when sleep regulation is needed, or increase appetite when that is desired. There are also depression medications that reduce sleep, relieve pain or nausea and are used safely in patients with cancer.

Myth 3: Psychiatric medications cause addiction and turn people into zombies or robots!

Contrary to common belief, antidepressants are not addictive. Some psychiatric medications other than antidepressants do have addictive potential, but when used under medical supervision at the recommended dose and duration, they provide benefit rather than harm; that is why they became medications. Psychiatric drugs have specific initiation and gradual-discontinuation procedures. Following these rules minimizes side effects while maximizing benefit.

In summary...

Not every patient with cancer will experience depression. Unfortunately, however, it occurs 3-4 times as often among patients with cancer as in the general population. Patients, relatives and treatment teams must remain alert to depression symptoms. Unrecognized and untreated depression seriously impairs treatment and its success, in addition to reducing quality of life.