Cancer and Emotions: Is it Normal to be Depressed?

Cancer and Emotions: Is it Normal to be Depressed?
Article By Michelle B. Riba, M.D., M.S.
Director, Psycho-Oncology Program
University of Michigan Comprehensive Cancer Center

Often, my patients tell me that dealing with the emotions of cancer is actually harder than coping with the other medical problems. What are the emotions of cancer and how do we identify and treat these types of difficulties?
The main categories of psychological distress for patients with cancer include adjustment problems; depression; and anxiety. Other forms of psychiatric distress may relate to delirium and substance abuse. Distress may also occur from such difficulties as pain management; faith/spirituality; difficulties with family; work related problems; financial issues; worries about children; etc. Cancer is all encompassing for patients, and often for their families. It is no surprise, therefore, that we see about 50% of patients with cancer having some form of diagnosable psychiatric disorder sometime during their course of care.
It is however, very difficult for physicians, nurses, and patients themselves to identify psychiatric distress. For one thing, many of the symptoms of depression, anxiety, etc overlap with the cancer treatments themselves. There is a perceived stigma by some people of having a psychiatric problem. It is also very difficult to add on another problem to an already complex medical diagnosis. Patients sometimes feel embarrassed or ashamed that they are feeling sad or anxious. They can be afraid that if they raise issues, the cancer treatment will be discontinued or the physician will see them in a negative light. Physicians too often don’t want to raise issues that might be of a more sensitive nature for patients. So, there is a “Don’t ask, don’t tell� type of dynamic that sometimes occurs in doctor-patient relationships in cancer care.
Screening for psychiatric problems should be part of the routine care at all visits for cancer patients. The National Comprehensive Cancer Network (NCCN) has in fact developed guidelines for distress to help patients and practitioners provide such screening. Using a thermometer that helps patients self-identify where their level of distress lies on the scale, the tool provides a mechanism for the patient and clinicians to begin to talk about distress. Once distress has been identified, the patient can be evaluated for the specific type of psychiatric problem and a treatment plan organized.
Factors that influence whether patients will have psychiatric distress include the type of cancer and its site. For example, pancreatic cancer and certain types of lung cancer and advanced stages of cancer at time of diagnosis portend more of an incidence of psychiatric problems. Similarly, patients who are young or old; those who are not married or have little support; those who have few friends or not affiliated with community or religious groups; those patients with a history of psychiatric problems; and those with concomitant medical problems have more psychiatric difficulties.
One of the issues that comes up is “Isn’t it normal to be depressed or anxious?� The answer is yes and no. There is a continuum of emotions—at the time of diagnosis, many patients do feel sad and worried. This is especially so when there is difficulty making a diagnosis (many tests, second or third opinions, difference of opinions) or when a diagnosis is missed. Around this time, we often see patients having problems going to sleep and staying asleep. They are worried about the future and are beginning to think of the impact of the diagnosis and treatment on their families, jobs, future. Once a diagnosis and treatment plan is made, most patients begin to feel confidence. The hope that a physician is able to transmit to the patient and family is very important. Giving consistent, clear information that is understandable by the patient and family helps tremendously. In addition, when patients know ahead of time what to expect, they can prepare. This helps diminish the distress as well.
During the diagnosis phase and into treatment, there are many chemotherapy agents that can influence mood. Steroids, some of the platinum-based compounds (e.g. cisplatinum) and high dose alpha interferon are some of the examples of medications that can highly affect mood and cognition. These medications can make patients feel very anxious, jittery, depressed and even manic. In some cases, these agents have been known to cause patients to feel suicidal or psychotic.
Many of the chemotherapy agents influence weight – they cause a decrease in appetite or in the case of steroids, and increase in fluid retention and weight. This can impact on body image. They can influence sleep – high dose steroids can make it difficult for patients to fall asleep and stay asleep. The fatigue of cancer influences energy levels. Hair loss caused by chemotherapy agents can trigger depression for many women, in particular. Additionally, many of the chemotherapy agents, especially some of the hormonal treatments, can impact negatively on sexual desire and feelings .
The symptoms of major depression include change in appetite; problems with falling asleep or staying asleep; depressed mood; feelings of hopelessness or helplessness; suicidal feelings; decrease in energy; decrease in the capacity to enjoy things; problems with concentration; psychomotor agitation or retardation. When patients have a multiple number of symptoms for at least two weeks, it is time to get evaluated for a psychiatric problem. Because symptoms of depression overlap with the effects of cancer treatment , a knowledgeable professional must make the evaluation with the patient and family.
Another time for added distress is when the active cancer treatment is complete. It is at this point that the patient must try to “reenter� life while at the same time coming for check ups to the oncologist to look for relapse. This is a very, very difficult time and patients and families often have a lot of emotional problems. There may be an expectation that the patient will be able to resume his/her previous chores around the house; go back to a regular work schedule; start socializing again. Often, all of these are difficult. The fatigue of cancer can last long after the active treatment. There is often a change in priorities or life values that the patient now has after going through the cancer diagnosis and treatment. There are changes in body image, sexual feelings and desire, and sometimes a decision to try to make major changes in life, without the partner being fully aware of the emotional changes that have occurred.
There are a number of treatment options for these types of emotional issues. After a good psychiatric evaluation and diagnosis, the options for care will follow. Treatment options may include psychotherapy (supportive; cognitive behavioral; psychodynamic; interpersonal; dialectic behavioral; etc). In addition, there are a host of antidepressant medications and anxiolytic agents that can help with mood and sleep problems. Couples and family therapy are very, very important. In addition, group therapy can be quite helpful, either supportive or supportive/expressive types of group therapy. While most types of psychiatric care are now provided in the outpatient setting, for more serious types of problems such as suicidality, homocidality or psychosis, inpatient treatment is also available.
In sum, it is critically important to be evaluated and treated for the emotional aspects of cancer care. Screening and detection are the first steps. Patients and families should make it a point of talking to their doctors about their emotional feelings. It is important not to assume “that it is normal� to feel anxious, depressed, overwhelmed, etc. If you do feel depressed, anxious, or confused and generally not like yourself, you or your family should ask about the cause and treatment of these symptoms.
It is also important for doctors and nurses to initiate asking patients about their levels of distress and that patients feel that they can answer these questions without prejudice. If you do have symptoms, you should be seen by a mental health professional who is trained to evaluate psychiatric problems (psychiatrist; psychologist; social worker; etc) and an appropriate treatment plan developed. Family members should be encouraged to participate in the development and implementation of the treatment plan. Insurance and managed care companies will hopefully support the treatment plan to ensure the optimal health of the patient. Patients with cancer will do better medically if emotional and psychological needs are addressed.

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