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• Introduction
• Overview
• Diagnosis
• Treatment
• Evaluation and Treatment of Suicidal Patients with Cancer
• Assisted Dying, Euthanasia, and Decisions Regarding End of Life
• Palliative Sedation
• Considerations for Depression in Children
• Questions or Comments About This Summary

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Diagnosis

The symptoms of major depression include the following:

• Having a depressed mood for most of the day and on most days.
• Loss of pleasure and interest in most activities.
• Changes in eating and sleeping habits.
• Nervousness or sluggishness.
• Tiredness.
• Feelings of worthlessness or inappropriate guilt.
• Poor concentration.
• Constant thoughts of death or suicide.

To make a diagnosis of depression, these symptoms should be present on most days for at least 2 weeks. The diagnosis of depression can be difficult to make in people with cancer due to the difficulty of separating the symptoms of depression from the side effects of medications or the symptoms of cancer. This is especially true in patients undergoing active cancer treatment or those with advanced disease. Symptoms of guilt, worthlessness, hopelessness, thoughts of suicide, and loss of pleasure are the most useful in diagnosing depression in people who have cancer.

Some people with cancer may have a higher risk for developing depression. The cause of depression is not known, but the risk factors for developing depression are known. Risk factors may be cancer-related and noncancer-related.

• Cancer-Related Risk Factors:
  • Depression at the time of cancer diagnosis.
  • Poorly controlled pain.
  • An advanced stage of cancer.
  • Increased physical impairment or pain.
  • Pancreatic cancer.
  • Being unmarried and having head and neck cancer.
  • Treatment with some anticancer drugs.
• Noncancer-Related Risk Factors:
  • History of depression.
  • Lack of family support.
  • Other life events that cause stress.
  • Family history of depression or suicide.
  • Previous suicide attempts.
  • History of alcoholism or drug abuse.
  • Having many illnesses at the same time that produce symptoms of depression (such as stroke or heart attack).

The evaluation of depression in people with cancer should include a careful evaluation of the person's thoughts about the illness; medical history; personal or family history of depression or suicide; current mental status; physical status; side effects of treatment and the disease; other stresses in the person's life; and support available to the patient. Thinking of suicide, when it occurs, is frightening for the individual, for the health care worker, and for the family. Suicidal statements may range from an offhand comment resulting from frustration or disgust with a treatment course, such as "If I have to have one more bone marrow aspiration this year, I'll jump out the window," to a statement indicating deep despair and an emergency situation, such as, "I can't stand what this disease is doing to all of us, and I am going to kill myself." Exploring the seriousness of these thoughts is important. If the thoughts of suicide seem to be serious, then the patient should be referred to a psychiatrist or psychologist, and the safety of the patient should be secured.

The most common type of depression in people with cancer is called reactive depression. This shows up as feeling moody and being unable to perform usual activities. The symptoms last longer and are more pronounced than a normal and expected reaction but do not meet the criteria for major depression. When these symptoms greatly interfere with a person's daily activities, such as work, school, shopping, or caring for a household, they should be treated in the same way that major depression is treated (such as crisis intervention, counseling, and medication, especially with drugs that can quickly relieve distressing symptoms). Basing the diagnosis on just these symptoms can be a problem in a person with advanced cancer since the illness may be causing decreased functioning. It is important to identify the difference between fatigue and depression since they can be assessed and treated separately. In more advanced illness, focusing on despair, guilty thoughts, and a total lack of enjoyment of life is helpful in diagnosing depression. (Refer to the PDQ summary on Adjustment to Cancer: Anxiety and Distress for further information.)

Medical factors may also cause symptoms of depression in patients with cancer. Medication usually helps this type of depression more effectively than counseling, especially if the medical factors cannot be changed (for example, dosages of the medications that are causing the depression cannot be changed or stopped). Some medical causes of depression in patients with cancer include uncontrolled pain; abnormal levels of calcium, sodium, or potassium in the blood; anemia; vitamin B 12 or folate deficiency; fever; and abnormal levels of thyroid hormone or steroids in the blood.