By Dr Neelima Sagi, MBBS, MRCPsych, Consultant Psychiatrist, Peterborough, UK

Depression is a leading cause of disability worldwide. Mild to major depression is common in cancer patients. Up to 24% of all cancer patients can have depression, more so while they are on treatment. Patients who have end stage cancer and those on palliative care are also known to have depression. Having depression has been shown to impact the course of cancer and compliance to treatment. It may also interfere with a patient’s ability to cope with the burden of illness. Early diagnosis and treatment of depression will improve cancer prognosis and quality of life.

Depression is more than feeling unhappy or fed up for a few days. The diagnosis of depression is given when one feels low in mood, has poor energy levels and loss of interests for at least 2 weeks. The narrow line between unhappiness and depression is that the latter causes disruption of day to day living. Sleep, appetite, and concentration levels could also be affected. Anxiety, tearfulness, low self-esteem, guilt feelings, pessimistic thoughts, hopelessness, and thoughts of suicide are found in moderate to severe depression.

There can be several contributing factors that can lead to depression in cancer patients. Reaction to a diagnosis of cancer, adjusting to life-style changes, treatment side effects and uncertainty of the future are the common factors. People with anxious and dependent types of personalities, who have previous or family history of depression, those with poor socio-economic status and a lack of social support are vulnerable to depression.

Depression can be left undiagnosed in cancer patients. Symptoms of depression can be missed due to the overlap of physical health symptoms caused by cancer and its treatment. Lethargy, agitation, loss of appetite, pain, nausea, and breathlessness can be secondary to both depression and cancer. Suspecting its presence by the patient, family, and the doctor, followed by a detailed assessment will help make a diagnosis.

Depression is a very treatable condition and antidepressants are the commonly prescribed drugs to people with depression. Newer antidepressants are better tolerated compared to the older ones. There has been a long-standing stigma associated with antidepressants, that patients could become drugged up and dependent on them. This is a myth. They do not cause psychological dependence [craving] and most newer drugs do not cause over sedation. The use of antidepressants in cancer patients is considered depending on the severity of depression, physical health issues and frailty.

Majority of patients taking antidepressants benefit from them. They could take 2 to 8 weeks to show some response, hence a trial of at least 2 months is advised before assessing their effectiveness. Side effects of antidepressants vary with the type and dose of medication. Some side effects can wear off after a week. If not, an alternative antidepressant can be considered. The dose of antidepressant is usually started low and gradually built up depending on the tolerability of the patient. Stopping them suddenly can cause withdrawal symptoms like irritability and anxiety. Hence, they should be tapered slowly under doctor’s advice.

There are several types of psychotherapies or talking therapies which could help with symptoms of depression. Commonly used therapy in cancer patients with depression is cognitive behavioral therapy [CBT]. In CBT, the therapist helps the patient to identify the association between the behavior, thoughts, and feelings. They will recommend structured strategies to help break the cycle. Patients will learn to recognize negative thoughts and feelings and will be able to control them under the therapist’s guidance through homework and mental exercises.

ECT, Electro convulsive therapy is a form of treatment for severe/major depression. It is considered for depression when antidepressants are ineffective. In severe depression patients may stop eating, sleeping, or talking to other people. They might imagine things which are not actually happening in real life, which leads to suspiciousness, suicidal thoughts, and aggressive behavior. In these situations, ECT works quicker than antidepressants. Cancer patients can be assessed to see if they are fit for ECT.

ECT is given in hospital as a day procedure and usually patients recover and will return home within 8 hours after the session. During the procedure patients are given a muscle relaxant and an anesthetic agent which puts them to sleep for approximately 10 minutes. Electrodes are placed on patient’s head to deliver short, controlled set of electric impulses for a few seconds. They must produce a seizure which will in turn help increase certain chemicals in the brain causing an improvement in mood. Patients will not feel the seizures or any associated pain during the treatment. The side effects of ECT are short term confusion and headaches.

Other therapies that could be helpful to improve the quality of life of cancer patients are carer education and support, anxiety management, and mindfulness. Carer support and respite is vital. The impact of cancer diagnosis on spouse and close family members is huge. Carers need to be given opportunity and space to vent out their stress and feelings. One must remember that the carer should continue to have some normality in their life and that they might need some time away from the role of care. This can be facilitated with additional support from care agencies, extended family support and/or a short break. Respite helps the carer to improve their mental and physical strength, which is essential to support their loved one with cancer.

Diagnosis of cancer and its repercussions can become a highly sensitive subject for discussion amongst the family members. It can lead to emotional outbursts and arguments damaging interpersonal relationships. The discussions about prognosis, treatment plans and future planning can be directed and supported by a counsellor if needed.

Stigma associated around mental health issues has gone down over the last decade. More and more people are aware of depression and are coming forward to access treatment. Diagnosing and treating depression in cancer patients is important. There are wide range of services provided by psychiatrists, psychologists, and holistic therapists to help patients with depression. Online self-help and charity services are also playing a substantial part in providing support to patients with mental health problems.