About 30 to 40 percent of people will experience significant distress after learning that they have cancer, according to James C. Coyne, Ph.D, director of the Behavioral Oncology Program at the Abramson Cancer Center and professor of psychology at the University of Pennsylvania School of Medicine. But it tends to resolve after three or four months, he said.
Clinical depression, however, affects about 16 percent of cancer patients, according to a 2011 study published in The Lancet Oncology. Researchers analyzed 94 studies with more than 14,000 patients. Depression was especially common — with 30 to 40 percent of patients affected — when other mood disorders were present.
Depression also appears to affect people with certain cancers to a greater degree, such as oropharyngeal (22–57 percent), pancreatic (33–50 percent), breast (2–46 percent) and lung cancers (11–44 percent), according to Derek Hopko, Ph.D, associate professor at The University of Tennessee and co-author of A Cancer Patient’s Guide to Overcoming Depression and Anxiety: Getting Through Treatment and Getting Back to Your Life.
The Difficulty of Making an Accurate Diagnosis
Many of the symptoms of depression, such as appetite and sleep changes, fatigue, lack of energy, cognitive impairment and loss of interest in previously pleasurable activities, already strike cancer patients because of the disease and its treatment. So it can be tough to spot depression. “Under-recognition of depression in cancer patients is common,” Hopko said.
For more accurate diagnosis, two approaches have been suggested, which vary based on the purpose of the diagnosis. For research purposes, an “exclusive approach” is recommended, which excludes fatigue, diminished appetite and weight loss, Hopko said. “Only four of the remaining DSM-IV symptoms are required to meet a diagnosis of major depression.” For clinical purposes, an inclusive approach is better.
There are several symptoms that serve as red flags that an intervention is needed. According to Coyne, these are anhedonia (loss of interest in activities they used to enjoy), mild insomnia and profound fatigue. Patients feel so slowed down that it takes enormous effort to do anything, he said.
Hopko added that other factors can complicate a correct diagnosis of depression: both patients and physicians may be unaware of symptoms; patients might be afraid of being stigmatized for having a mental illness; and brief outpatient visits don’t allow for comprehensive evaluations.
Depression’s Impact on Cancer Recovery
Depression has been linked to lower optimism concerning the effects of cancer interventions, Hopko said. Also, depression can lead to poor treatment adherence. “Cancer often pulls you out of your life. And if you’re already pulled out of your life, depression will aggravate that problem,” Coyne said.
Research has shown that psychotherapy successfully decreases depression symptoms in cancer patients. For instance, Hopko et. al (2008) found that a brief cognitive-behavioral therapy was effective in treating depressed cancer patients at a medical care setting, and these gains remained at the three-month follow-up.
In a more recent study, Hopko and colleagues (2011) found that in a sample of 80 women with depression and breast cancer, both brief behavioral activation treatment and problem-solving therapy improved symptoms, and gains remained after one year.
Coyne has found in his research that prescriptions for antidepressants outnumber depression rates in cancer patients. Distress over a cancer diagnosis is not the same thing as having clinical depression. As he said, an antidepressant isn’t a happy pill. So “If a person isn’t clinically depressed, they’re going to experience side effects [from an antidepressant] without getting benefits.” Also, in some instances, antidepressants may interfere with hormonal therapy, he said. “It’s not a neutral decision.”
When choosing a therapist, work with a professional who’s informed about the nature of cancer and doesn’t project their own fears, Coyne said. “It’s important to find a therapist that’s either open to learning from the patient or has a solid background working with cancer patients,” he said. Consult your oncologist or primary care physician for referrals. For more advanced cancer, existential therapy may be helpful, he added.
Correction: It’s not mild insomnia that’s a red flag — it’s middle insomnia. This is when depressed patients sometimes find themselves the most alert in the middle of the night when everybody else is sleeping.