Depressive disorders and symptoms are common in cancer patients (up to 58% have depressive symptoms and up to 38% have major depression),1-3 worsen over the course of cancer treatment, persist long after cancer therapy,4 recur with the recurrence of cancer,5 and significantly impact quality of life.6-9 Depressive symptom prevalence varies by cancer site, stage, and treatment, as well as by the methods and criteria used in assessing depression. October 2006 –Unfortunately, clinicians and patients often perceive depression as an expected and reasonable reaction to cancer; as a result, depression is frequently under recognized and under treated in oncology practice.10-15 Failure to effectively manage depressive symptoms results from patient, provider, and health system barriers to care. Patients may be reluctant to report symptoms or to see a mental health professional and if treatment is prescribed, they may be non adherent, citing concerns about side effects and/or preoccupation with active cancer treatment. Providers may be reluctant to raise the issue, be less aware of effective treatment, and/or lack access to mental health professionals.
It is not surprising that low-income patients are particularly unlikely to receive mental health treatment.16,17 In addition, culturally based preferences for depression care can become a barrier if the preferred mode of care is not available.18 Personal culturally based explanations for depressive symptoms may influence symptom expression and patient-provider communication.19-21 Finally, patient perceptions of bias and cultural competence in health care, family perceptions, and practical barriers, such as cost and transportation to therapy, may impede receipt of care.22,23
ASSESSING DEPRESSION AND RELATED SYMPTOMS
Establishing a diagnosis of clinical depression among cancer patients is confounded by biologic and physical symptoms as well as psychological stress attributable to the disease or its treatment.24-27 Cancer and its treatment-related symptoms (fatigue, anorexia, sleep disturbance, and pain) can mask a depression or contribute to its development and persistence.
Difficulty in differentiating the symptoms of depression from those of the medical illness makes the identification and treatment of patients with depression challenging. Indeed, there has been discussion that the presence of depression in medical illnesses such as cancer represents a broader pathophysiologic syndrome known as “sickness syndrome,” a behavior or group of symptoms occurring under chronic immune stimulation.28
Assessment of depression should include discussion about common symptoms experienced by patients as well as general distress management,29 and these discussions should continue over the duration of the illness. In fact, a clinical perspective of comorbid cancer and depression is best understood in relation to a staged trajectory of illness from diagnosis to treatment to chronic illness management or “cancer survivorship.” Cancer survivorship is a term that has come to represent the state or process of living, following a diagnosis of cancer, regardless of how long a person lives. Thus, treating the patient for depression may be indicated at any stage in the illness trajectory.
The National Cancer Institute (NCI) Web site advises clinicians that “evaluation of depression in people with cancer should also include a careful assessment of the person’s perception of the illness, medical history, personal or family history of depression or thoughts of suicide, current mental status, and physical status, as well as treatment and disease effects, concurrent life stressors, and availability of social supports. . . . Suicidal statements may range from an offhand comment resulting from frustration or disgust with a treatment course: ‘If I have to have one more bone marrow aspiration this year, I’ll jump out the window,’ to a reflection of significant despair and an emergent situation: ‘I can no longer bear what this disease is doing to all of us, and I am going to kill myself.’ Exploring the seriousness of the thoughts is imperative.”30
Based on our experience, we would add that it is important to assess potential cultural differences in the patient’s personal conceptions of both depression and cancer. For example, many of our Hispanic patients attribute the etiology of depression to life stresses and to cancer-related stress in particular. They also prefer psychotherapy to medication and express the belief that stress can make the cancer worse.
The precise physiologic links between depression and cancer are unknown, although various hypotheses have been discussed in the literature. One of those is dysfunction of the hypothalamic- pituitary-adrenal (HPA) axis. Hyperactivity of the HPA axis is manifested in increased urinary free cortisol levels, dexamethasone non suppression, blunted corticotropin response to corticotropin-releasing factor (CRF), increased cerebrospinal fluid CRF concentrations, and adrenal and pituitary hypertrophy.28 Diagnostic findings such as these have been reported in depressed patients with and without cancer.
A few studies have demonstrated that many cancer patients have dys regulation of the HPA axis similar to that of depressed patients without cancer. Evans and colleagues31 found that 40% of their female patients with depression exhibited dexamethasone non suppression. However, the small number of studies as well as the limited number of patients studied precludes final determination of the clinical usefulness of dexamethasone suppression testing for all cancer patients with depression.
Several investigators have examined the relationship between HPA axis hyperactivity and immune dysfunction in medically ill cancer patients. Cytokines–hormones that are secreted by cells of the immune system and that act as inflammatory mediators–have been shown to affect neurotransmitter function, neuroendocrine function, and behavior.19 Stress-induced cytokine release or HPA hyperactivity in patients with cancer may cause changes in immunologic function. Pro inflammatory cytokines such as interleukin-1, interleukin-6, and tumor necrosis factor can activate the HPA axis, as well as change the metabolism of neurotransmitters such as norepinephrine, serotonin, and dopamine.32 These neuroendocrine and immunologic effects can contribute to the presentation of depressed mood, fatigue, anorexia, pain, or sickness syndrome. Future research in this field has implications not only for diagnosis but more important, for therapy.
A broad range of psychosocial and psychological interventions have been reported to aid in reducing depression and accompanying anxiety, enhancing coping skills, and improving quality of life in patients with cancer.33-37 In general, more convincing effects are found for patients screened at baseline36,38; however, few studies have targeted patients with depressive disorders,39 and because the majority of studies have been of white women,40 the evidence is relatively weak for other populations.
A systematic review by Williams and Dale41 of 24 randomized controlled trials of either pharmacologic or psychotherapeutic interventions for cancer patients with depression or depressive symptoms recently concluded that depression in cancer patients is responsive to antidepressant medication treatment, although some studies reported high dropout rates and some failed to report adverse events or tolerability. For example, paroxetine was useful in reducing major depression in patients with malignant melanoma who were receiving high-dose interferon alpha treatment42 and in reducing depressive symptoms in patients with breast cancer who were undergoing chemotherapy.43 In a trial by Fisch and colleagues,44 fluoxetine was effective in reducing depressive symptoms in patients with solid tumors.
Other studies not analyzed by Williams and Dale report that the tetracyclic antidepressant mianserin reduced depressive symptoms in patients with breast cancer and that tricyclic antidepressants such as amitriptyline and desipramine are also useful in the treatment of depression in cancer.45,46 An open-label study of mirtazapine in cancer patients with depression showed improved functionality and reduced depressive and anorexic symptoms.47 The tolerability of the above antidepressants appears to be generally good in patients with cancer. Patients may experience adverse effects, but such effects may be complicated by treatment of the cancer itself.
As already suggested, it is important to consider the treatment implications of simultaneously managing depression and pain and fatigue in patients with cancer using a variety of evidence-based interventions.24,48,49 In addition to alleviating symptoms of depression, antidepressant medications may provide relief of related cancer symptoms. For example, fluoxetine, paroxetine, and venlafaxine have been effective in reducing hot flashes in patients with cancer.50-52 Patients may have neuropathic pain from the cancer or the treatments, and bupropion, the tricyclic antidepressants, and venlafaxine have demonstrated the ability to reduce neuropathic pain.53-55 Avoiding significant drug interactions in patients on complex chemotherapeutic and pain management regimens requires careful monitoring.26,56 The NCI Web site provides detailed pharmacologic treatment algorithms that are consistent with current knowledge.
There is growing consensus that structured psychotherapy, alone or combined with antidepressant treatment, is effective in treating depression.57 Under some circumstances, it is the treatment of choice (ie, when preferred by individual patients, when pharmacologic treatments are contraindicated, and for patients coping with low social support or environmental stressors; or for maintenance after discontinuation of antidepressant medication). Clinical benefits from psychotherapy should be evident within 6 to 8 weeks. Medications should be considered for patients who fail to improve by that time and for those who do not have full remission after 12 weeks of psychotherapy. Structured psychosocial therapies are as effective as antidepressants for moderate depression and may be more effective in reducing recurrence.58
In a report based on their systematic review of the literature on psychotherapeutic interventions for people with cancer, Williams and Dale41 concluded that cognitive-behavioral therapy (CBT) appears to be effective, as does social support, in reducing depressive symptoms. CBT challenges pessimistic or self-critical thoughts, emphasizes rewarding activities, and decreases behavior that reinforces depression. Alternative modes of delivery of CBT have been explored, including group CBT and telephone or computer self-help formats.59
Problem-solving therapy (PST) uses behavior activation components of CBT but with less emphasis on changing cognition and greater emphasis on patient assessment of personal contextual problems and skill-building to enhance self-management skills.60 PST adapted for primary care in the multicenter IMPACT study61 was found to significantly reduce depressive symptoms in older primary care patients, including African American and Hispanic patients, with major depression or dysthymia,57 and PST was found effective in reducing depres- sive symptoms in patients with cancer.15,60,62-65 The brief psychoeduca- tional characteristics of PST make it feasible to provide and acceptable to patients with a wide range of educational levels. PST is available in published treatment manuals for depression and for coping with cancer. According to the PST theoretical framework, experiencing negative life events (such as cancer) can lead to the occurrence of a wide range of daily problems that are believed to be sources of stress that trigger depressive symptoms. Increasing problem-solving skills has been shown to reduce depressive symptoms.
REDUCING BARRIERS AND IMPROVING ADHERENCE
Quality-improvement strategies have been shown to be effective in reducing barriers to depression care.66 Organizational strategies generally include multifaceted quality-improvement disease-management interventions that change the way in which depression care is delivered, such as the implementation of routine depression screening, systematic application of evidence-based practice guidelines, clinical decision-making protocols and algorithms (cancer-specific algorithms available on the NCI and National Comprehensive Cancer Network Web sites29,30), follow-up through remission and maintenance, enhanced roles of nurses or social workers as depression care managers, as well as integration between primary care and mental health specialists or service systems.67
Depression care models that use collaboration between primary care physicians and mental health professionals, in which expertise in psychopharmacology in treating depression is provided by a psychiatrist and PST and supportive care management is provided by depression specialist nurses or social workers, has been found to be effective in primary care.57 A model adapted for oncology was found to be effective in a pilot study that included 55 low-income Hispanic patients with breast or cervical cancer, all of whom met criteria for major depression.68 The patients were randomized to either intervention or usual care and results suggested that cancer patients in public sector oncology clinics can benefit from depression treatment. A full-scale trial consisting of 425 low-income ethnic minority patients with cancer is currently under way using this model. Collaborative interventions have also been found to improve patient adherence and prevent relapse.69
Persons with cancer are under served with respect to receipt of current guideline-level care for major depression. We agree with Williams and Dale41 that patients should not be denied treatment for depression while the efforts to find further evidence of its effectiveness progress. Psychiatrists, as specialty medical consultants, can play a vital role in advocating optimal mental health care for medically ill cancer patient with depression. For psychiatrists treating patients with depression and cancer, it is imperative that the symptoms of depression are identified and that the goal of treatment is remission of depressive symptoms via the modalities mentioned previously. Psychiatrists with medical understanding of the biologic correlations between depression and cancer are in a good position to advocate effective treatment of the patient’s comorbid medical conditions. These can include pain and the adverse effects of medical treatments for cancer that can contribute to the patient’s experience of depression. In doing so, the patient’s psychiatric and medical responses to both depression and cancer treatments may be optimized.
Dr Ell is the Ernest P. Larson Professor of Poverty, Ethnicity, and Health at the School of Social Work of the University of Southern California in Los Angeles. Dr Quon is assistant professor of clinical psychiatry at the Keck School of Medicine of the University of Southern California in Los Angeles. They report that they have no conflicts of interest with the subject matter of this article.
Drugs mentioned in this article
Amitriptyline (Elavil, Endep)
Desipramine (Norpramin, Pertofrane)
Mianserin (Bolvidon, Norval, Tolvan )
1. Honda K, Goodwin RD. Cancer and mental disorders in a national community sample: findings from the National Comorbidity Survey. Psychother Psychosom. 2004;73:235-242.
2. Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004;32:57-71.
3. Pirl WF. Evidence report on the occurrence, assessment, and treatment of depression in cancer patients. J Natl Cancer Inst Monogr. 2004;32:32-39.
4. Thompson DS, Shear MK. Psychiatric disorders and gynecological oncology: a review of the literature. Gen Hosp Psychiatry. 1998;20:241-247.
5. Okano Y, Okamura H, Watanabe T, et al. Mental adjustment to first recurrence and correlated factors in patients with breast cancer. Breast Cancer Res Treat. 2001; 67:255-262.
6. Ahlberg K, Ekman T, Wallgren A, Gaston-Johansson F. Fatigue, psychological distress, coping and quality of life in patients with uterine cancer. J Adv Nurs. 2004;45: 205-213.
7. Brown KW, Levy AR, Rosberger Z, Edgar L. Psychological distress and cancer survival: a follow-up 10 years after diagnosis. Psychosom Med. 2003;65: 636-643.
8. Goodwin JS, Zhang DD, Ostir GV. Effect of depression on diagnosis, treatment, and survival of older women with breast cancer. J Am Geriatr Soc. 2004;52:106-111.
9. Hjerl K, Andersen EW, Keiding N, et al. Depression as a prognostic factor for breast cancer mortality. Psychosomatics. 2003;44:24-30.
10. Passik SD, Dugan W, McDonald MV, et al. Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol. 1998;16:1594-1600.
11. Ashbury FD, Madlensky L, Raich P, et al. Antidepressant prescribing in community cancer care. Support Care Cancer. 2003;11:278-285.
12. Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer. 2001;84:1011-1015.
13. McDonald MV, Passik SD, Dugan W, et al. Nurses’ recognition of depression in their patients with cancer. Oncol Nurs Forum. 1999;26:593-599.
14. Newell S, Sanson-Fisher RW, Girgis A, Bonaventura A. How well do medical oncologists’ perceptions reflect their patients’ reported physical and psychosocial problems? Data from a survey of five oncologists. Cancer. 1998;83:1640-1651.
15. Strong V, Sharpe M, Cull A, et al. Can oncology nurses treat depression? A pilot project. J Advan Nurs. 2004;46:542-548.
16. Ell K, Sanchez K, Vourlekis B, et al. Depression, receipt of depression care, and correlates of depression among low-income women with breast or gynecological cancer. J Clin Oncol. 2005;23:3052-3060.
17. Hewitt M, Rowland JH. Mental health service use among adult cancer survivors: analyses of the National Health Interview Study. J Clin Oncol. 2002;20: 4581-4590.
18. Cooper-Patrick L, Powe NR, Jenckes MW, et al. Identification of patient attitudes and preferences regarding treatment of depression. J Gen Intern Med. 1997;12:431-438.
19. Gallo JJ, Cooper-Patrick L, Lesikar S. Depressive symptoms of whites and African Americans aged 60 years and older. J Gerontol B Psychol Sci Soc Sci. 1998; 53:P277-P286.
20. Marwaha S, Livingston G. Stigma, racism or choice: why do depressed ethnic elders avoid psychiatrists? J Affect Disord. 2002;72:257-265.
21. Mills TL, Alea NL, Cheong JA. Differences in the indicators of depressive symptoms among a community sample of African-American and Caucasian older adults. Community Ment Health J. 2004;40:309-331.
22. Miranda J, Duan N, Sherbourne CD, et al. Improving care for minorities: can quality improvement intervention improve care and outcomes for depressed minorities? Health Serv Res. 2003;38:613-630.
23. Johnson TK, Gilliland FD, Hoffman RM, et al. Racial/ethnic differences in functional outcomes in the 5 years after diagnosis of localized prostate cancer. J Clin Oncol. 2004;22:4193-4201.
24. Ciaramella A, Poli P. Assessment of depression among cancer patients: the role of pain, cancer type and treatment. Psychooncology. 2001;10:156-165.
25. Jacobsen PB, Donovan KA, Weitzner MA. Distinguishing fatigue and depression in patients with cancer. Semin Clin Neuropsychiatry. 2003;8:229-240.
26. Newport DJ, Nemeroff CB. Assessment and treatment of depression in the cancer patient. J Psychosom Res. 1998;45:215-237.
27. Trask PC. Assessment of depression in cancer patients. J Natl Cancer Inst Monogr. 2004;32:80-92.
28. Raison CL, Miller AH. Depression in cancer: new developments regarding diagnosis and treatment. Biol Psychiatry. 2003;54:283-294.
29. National Comprehensive Cancer Network. Clinical practice guidelines in oncology, distress management assessment tool. Available at: http://www.nccn.org/professionals/physician_gls/default.asp. Accessed July 15, 2006.
30. National Cancer Institute. Depression (PDQ): health professional version. January 4, 2006; Available at: http://www.cancer.gov/cancertopics/pdq/supportivecare/
depression/HealthProfessional/page3#Section_324. Accessed July 21, 2006.
31. Evans DL, McCartney CF, Nemeroff CB, et al. Depression in women treated for gynecological cancer: clinical and neuroendocrine assessment. Am J Psychiatry. 1986;143:447-452.
32. Dunn AJ, Wang J, Ando T. Effects of cytokines on cerebral neurotransmission. comparison with the effects of stress. Adv Exp Med Biol. 1999;461:117-127.
33. Fawzy FI, Fawzy NW, Arndt LA, Pasnau RO. Critical review of psychosocial interventions in cancer care. Arch Gen Psychiatry. 1995;52:100-113.
34. Holland JC. Preliminary guidelines for the treatment of distress. Oncology. 1997;11:109-114.
35. Rehse B, Pukrop R. Effects of psychosocial interventions on quality of life in adult cancer patients: meta analysis of 37 published controlled outcome studies. Patient Educ Couns. 2003;50:179-186.
36. Ross L, Boesen EH, Dalton SO, Johansen C. Mind and cancer: does psychosocial intervention improve survival and psychological well-being? Eur J Cancer. 2002;38:1447-1457.
37. van der Pompe G, Antoni M, Visser A, Garssen B. Adjustment to breast cancer: the psychobiological effects of psychosocial interventions. Patient Ed Couns. 1996;28:209-220.
38. Sheard T, Maguire P. The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses. Br J Cancer. 1999; 80:1770-1780.
39. Newell SA, Sanson-Fisher RW, Savolainen NJ. Systematic review of psychological therapies for cancer patients: overview and recommendations for future research. J Natl Cancer Inst. 2002;94:558-584.
40. Meyer TJ, Mark MM. Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol. 1995;14: 101-108.
41. Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer. 2006;94: 372-390.
42. Musselman DL, Lawson DH, Gumnick JF, et al. Paroxetine for the prevention of depression induced by high-dose interferon alfa. N Engl J Med. 2001;344: 961-966.
43. Roscoe JA, Morrow GR, Hickok JT, et al. Effect of paroxetine hydrochloride (Paxil) on fatigue and depression in breast cancer patients receiving chemotherapy. Breast Cancer Res Treat. 2005;89:243-249.
44. Fisch MJ, Loehrer PJ, Kristeller J, et al. Fluoxetine versus placebo in advanced cancer outpatients: a double-blinded trial of the Hoosier Oncology Group. J Clin Oncol. 2003;21:1937-1943.
45. Pezzella G, Moslinger-Gehmayr R, Contu A. Treatment of depression in patients with breast cancer: a comparison between paroxetine and amitriptyline. Breast Cancer Res Treat. 2001;70:1-10.
46. Holland JC, Romano SJ, Heilingenstein JH, et al. A controlled trial of fluoxetine and desipramine in depressed women with advanced cancer. Psycho- oncology. 1998;7:291-300.
47. Theobald DE, Kirsh KL, Holtsclaw E, et al. An open-label, crossover trial of mirtazapine (15 and 30 mg) in cancer patients with pain and other distressing symptoms. J Pain Symptom Manage. 2002;23:442-447.
48. Fisch M. Treatment of depression in cancer. J Natl Cancer Inst Monogr. 2004;32:105-111.
49. National Institutes of Health State-of-the-Science Conference on Symptom Management in Cancer: Pain, Depression, and Fatigue. Natl Cancer Inst Monogr. 2004; 32:1-157.
50. Loprinzi CL, Kugler JW, Sloan JA, et al. Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial. Lancet. 2000; 356:2059-2063.
51. Loprinzi CL, Sloan JA, Perez EA, et al. Phase III evaluation of fluoxetine for treatment of hot flashes. J Clin Oncol. 2002;20:1578-1583.
52. Stearns V, Isaacs C, Rowland J, et al. A pilot trial assessing the efficacy of paroxetine hydrochloride (Paxil) in controlling hot flashes in breast cancer survivors. Ann Oncol. 2000;11:17-22.
53. Max MB, Lynch SA, Muir J, et al. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med. 1992;326:1250-1256.
54. Semenchuk MR, Sherman S, Davis B. Double-blind, randomized trial of bupropion SR for the treatment of neuropathic pain. Neurology. 2001;57:1583-1588.
55. Sumpton JE, Moulin DE. Treatment of neuropathic pain with venlafaxine. Ann Pharmacother. 2001;35: 557-559.
56. Berney A, Stiefel R, Mazzacato C, Buclin T. Psychopharmacology in supportive care of cancer: a review for the clinician III. Antidepressants. 2000;8:278-286.
57. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288:2836-2845.
58. Reynolds CF III, Frank E, Perel JM, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA. 1999;281:39-45.
59. Proudfoot J, Goldberg D, Mann A, et al. Computerized, interactive, multimedia cognitive-behavioural program for anxiety and depression in general practice. Psychol Med. 2003;33:217-227.
60. Nezu A, Nezu CM, Friedman SH, et al. A Problem-Solving Approach: Helping Cancer Patients Cope. Washington, DC: American Psychological Association; 1998.
61. Haverkamp R, Arean P, Hegel MT, Unutzer J. Problem-solving treatment for complicated depression in late life: a case study in primary care. Perspect Psychiatr Care. 2004;40:45-52.
62. Allen SM, Shah AC, Nezu AM, et al. A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial. Cancer. 2002;94:3089-3100.
63. Nezu A, Nezu C, Houts P, et al. Cancer and psychological distress: the role of problem solving. J Psychosoc Oncol. 1999;16:27-40.
64. Nezu AM, Nezu CM, Felgoise SH, et al. Project genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients. J Consult Clin Psychol. 2003;71:1036-1047.
65. Sharpe M, Allen K, Strong V, et al. Major depression in outpatients attending a regional cancer centre: screening, prevalence and unmet treatment needs. Br J Cancer. 2004;90:314-320.
66. Wells K, Sherbourne C, Schoenbaum M, et al. Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial. Arch Gen Psychiatry. 2004;61:378-386.
67. Reuben DB. Organizational interventions to improve health outcomes of older persons. Med Care. 2002; 40:416-428.
68. Dwight-Johnson M, Ell K, Jiuan-Lee P. Can collaborative care address the needs of low-income Latinas with comorbid depression and cancer? Results from a randomized pilot study. Psychosomatics. 2005;46: 224-232.
69. Lin EH, Von Korff M, Ludman EJ, et al. Enhancing adherence to prevent depression relapse in primary care. Gen Hosp Psychiatry. 2003;25:303-310.
Kathleen Ell, DSW and Brenda Quon, MD
© 2006 CMP Healthcare Media Group LLC,
* Ciaramella A, Poli P. Assessment of depression among cancer patients: the role of pain, cancer type and treatment. Psychooncology. 2001;10:156-165.
* Fisch M. Treatment of depression in cancer. J Natl Cancer Inst Monogr. 2004;32:105-111.
*Forum Admin note: Co-Morbid Illnesses
Co-Morbid Illnesses demand more attention from both policy makers and from the medical community. Currently, too many people believe that depression is an inevitable part of a chronic illness. To change that, education must take place on many levels so people learn that depression is a separate illness that frequently co-occurs with illnesses like diabetes and coronary disease. Research has indicated that cancer patients are twice as likely as non-cancer patients to suffer from depression, that depression often precedes chemotherapy and helps trigger the onset of other health disorders as well. Health treatments are not as effective for people with depression. Similarly, The Journal of the American Medical Association (JAMA) reports that “major depression may play a role in an increased risk of death and hospitals readmissions for patients with congestive heart failure.” Similar statistics can be found in relation to people diagnosed with depression and AIDS or liver, pulmonary and Parkinson’s diseases. More research is needed to show more causal relationships.
People need to know that medical treatments have a greater success rate if the depression is treated as well as the physical disease.