Emotional Disorders

Discussed in the Section:

Post-Traumatic Stress Disorder
Anxiety
Depression





Post-Traumatic Stress Disorder

Better treatment of many cancers has resulted in more patients experiencing longer periods of disease-free survival. This has also led to more patients experiencing psychological problems, which are collectively called post-traumatic stress disorder. This brief summary describes post-traumatic stress disorder, its symptoms, and its treatment.

Overview

More patients are surviving cancer for longer periods of time than in the past due to better treatments. However, being diagnosed with cancer, being treated, and surviving cancer can cause psychological problems for some people.

Adult and child survivors of cancer may have problems with self-esteem, body image, intimacy, and sexuality. Patients may experience anxiety and depression related to fear of the cancer coming back and having to face one's own death. Some survivors of cancer experience trauma-related symptoms, such as avoiding situations, continuously thinking about problems, and being over-excited. These symptoms are similar to symptoms experienced by people who have survived highly stressful situations, such as combat, natural disasters, rape, or other life-threatening events. This group of symptoms is called post-traumatic stress disorder (PTSD).

People with histories of cancer are considered to be at risk for PTSD. The physical and mental shock of having a life-threatening disease, of receiving treatment for cancer, and living with repeated threats to one's body and life are traumatic experiences for many cancer patients.

Cancer patients commonly experience pain, tiredness, weakness, nausea, and/or vomiting. Cancer patients also often undergo painful, harmful, and invasive procedures. They may be in the hospital for long periods of time, leading to feelings of isolation and loss of control. These experiences may lead to feelings of helplessness, especially for patients who have certain risk factors, such as having little social support, experiencing a trauma, being victimized in the past, or having a history of mental disorder. Patients with a history of severe personality problems may have trouble giving up control (as cancer treatment often requires) while still feeling safe.

Applying PTSD to Cancer

One problem health professionals have in determining if a cancer patient has PTSD is figuring out what exactly is the cause of trauma. Because the cancer experience involves so many upsetting events, it is much more difficult to single out one event as a cause of stress than it is for other traumas, such as natural disasters or rape. For cancer patients, the stressful incident may be the initial diagnosis, realizing that the disease may be fatal, a long period of pain, a symptom that indicates the cancer has returned, a feared treatment procedure, or an unexpected incident (for example, being present when a hospital roommate is resuscitated or dies).

Diagnosis

PTSD is defined as the development of certain symptoms following a mentally stressful event that involved actual death or the threat of death, serious injury, or a threat to oneself or others. These events may include being diagnosed with a life-threatening illness or learning that one's child has a life-threatening illness. These events may cause responses of extreme fear, helplessness, or horror and may trigger PTSD symptoms. These symptoms include re-experiencing the trauma (nightmares, flashbacks, and interfering thoughts), continuously avoiding reminders of the trauma (avoiding situations, responding less to people, and showing less emotion), and being continuously excited (for example, having sleeping problems or being overly defensive, watchful, or irritable). Other common emotional responses include unhappiness, guilt over actions taken or not taken, and overwhelming loss.

Prevalence

In cancer, as in other stressful major life events, over-excitability, avoiding certain thoughts, and having intrusive thoughts are common. Some Hodgkin's disease patients have these symptoms even 6 years after their last treatments. Studies of head and neck cancer patients show that PTSD symptoms may show up shortly after diagnosis, as well as during and after treatment. In these studies, patients' symptoms were worse at the time of diagnosis and lessened during treatment, indicating that cancer is a series of traumas rather than a single traumatic event. Patients receiving cancer treatment, as well as cancer survivors, may be diagnosed with PTSD.

Some cancer survivors may have higher levels of general mental distress. People with a history of PTSD may be at risk for developing ongoing emotional problems.

Research of children who had survived cancer also reported the presence of PTSD symptoms. Stress responses of children after bone marrow transplantation showed that post-traumatic stress symptoms continued for at least 1 year after treatment.

Symptoms typical of PTSD have also been seen in family members of cancer patients and survivors. These symptoms may be due to family members having to face the patient's possible death as well as repeatedly witnessing treatments and side effects. Mothers and fathers tend to report more serious PTSD than do their children who have cancer. These symptoms do not appear to lessen over time. Partners (such as wives) of cancer patients may also experience PTSD symptoms more often than patients.

Causes and Risk Factors

PTSD is caused by an extremely upsetting event; however, this one event alone does not explain why some people get PTSD. Not everyone who experiences these upsetting events develops PTSD. For some people, mental, physical, or social factors may make them more likely to experience it. PTSD symptoms develop due to both adapting and learning. Adapting explains the fear responses caused by certain triggers that were first associated with the upsetting event. Neutral triggers (such as, smells, sounds, and sights) that occurred at the same time as upsetting triggers (for example, chemotherapy or painful treatment procedures) eventually cause anxiety, upset, and fear when occurring alone, even after the trauma has ended. Once established, PTSD symptoms are continued through learning. That is, avoiding certain triggers continues because this avoidance prevents unpleasant feelings and thoughts.

As many as one-third of people who experience traumatic events, including cancer, may develop PTSD. While this appears to be a learning process, other factors may influence who develops PTSD.

The most critical factors in determining who develops PTSD are the severity of the exposure, the length of the exposure, and the closeness of the person to the event. The suddenness of the event and the threat to life and body are also important for some people.

While the type of event is the main factor in how a person responds to a traumatic event, other individual and social factors may also play a role. Previous psychological problems, history of trauma, high levels of mental distress, and ineffective coping skills have been linked to a risk of PTSD. Genetic and other biologic factors (for example, hormone problems) may also make some people more at risk for PTSD. The amount of social support available has also been shown to affect the risk of PTSD.

The effect of threat to life and body has been shown in research on adults and families, but not in children. The presence of pain and other physical symptoms has been shown to coincide with levels of interfering thoughts. Cancer that has returned has also been shown to increase stress symptoms in patients. While the severity or intensity of treatment was not related to avoidance or interfering thoughts in adult survivors of cancer, they did cause symptoms in survivors of childhood cancer.

The time between diagnosis and treatment has been shown to cause PTSD symptoms in survivors of bone cancer and Hodgkin's disease. People for whom more time has passed since diagnosis and treatment tended to show fewer symptoms. However, this effect has not been seen in patients with cancer that has returned recently, survivors of breast cancer, or survivors of childhood cancer. The length of treatment, rather than the time since treatment, can be an indication of stress symptoms in survivors of childhood cancer.

Assessment

The most difficult decision to make in the diagnosis of PTSD is knowing when to evaluate the patient, since cancer is an experience of repeated traumas and undetermined length. The patient may experience stress symptoms anytime from diagnosis, through completion of treatment, and cancer recurrence. In patients who have a history of victimization (such as Holocaust survivors) and who have PTSD or its symptoms from these experiences, symptoms can be started again by any of the triggers experienced during their cancer treatment (for example, clinical procedures such as being inside MRI or CT scanners). While these patients may have problems adjusting to cancer and cancer treatment, their PTSD symptoms may vary, depending on other factors. The symptoms may become more or less prevalent during and after the cancer treatment.

Symptoms of PTSD usually begin within the first 3 months after the trauma, but sometimes they do not appear for months or even years afterwards. Therefore, cancer survivors and their families should be involved in long-term monitoring.

Some people who have experienced an upsetting event may show early symptoms without meeting the full diagnosis of PTSD. However, these early symptoms predict that PTSD may develop later. Early symptoms also indicate the need for repeated and long-term follow-up of cancer survivors and their families.

Diagnosing PTSD can be difficult since many of the symptoms are similar to other psychiatric problems. For example, irritability, poor concentration, increased defensiveness, excessive fear, and disturbed sleep are symptoms of both PTSD and anxiety disorder. Other symptoms are common to PTSD, phobias, and panic disorder. Some symptoms, such as loss of interest, a sense of having no future, avoidance of other people, and sleep problems may indicate the patient has PTSD or depression. Even without PTSD or other problems, normal reactions to the cancer diagnosis and treatment of a life-threatening disease can include interfering thoughts, separating from people and the world, sleep problems, and over-excitability.

Questionnaires and interviews are used by health care providers to assess if the patient has symptoms of stress and to determine the diagnosis.

Other problems may also exist in addition to PTSD. These problems can include substance abuse, emotional problems, and other anxiety disorders, including major depression, alcohol dependence, drug dependence, social fears, and/or obsessive-compulsive disorder.

Treatment

The chronic and sometimes disastrous effects of PTSD mean the disorder needs to be treated quickly. However, the avoidant symptoms that appear with PTSD often keep the patient from seeking help. Therapies used are those used for other trauma victims and involve more than one type of therapy.

The crisis intervention method tries to lessen the symptoms and return patients to their normal level of functioning. The therapist focuses on solving problems, teaching coping skills, and providing a supportive setting for the patient.

Thinking-behavior methods have been very helpful. Some of these methods include helping the patient understand symptoms, teaching coping and stress management skills (such as relaxation training), reforming one's thinking, and trying to make the patient less sensitive to the symptoms. Behavior therapy is used when the symptoms are avoidance of sexual activity and intimate situations.

Support groups may also help people who experience post-traumatic stress symptoms. In the group setting, patients can receive emotional support, meet others with similar experiences and symptoms, and learn coping and management skills.

For patients with severe symptoms, medications may be used. These include antidepressants, antianxiety medications, and when necessary, antipsychotic medications.




Anxiety

Anxiety is a normal reaction to cancer, but it can interfere with a patient's quality of life and the ability to follow through with cancer therapy. This brief summary describes the causes and treatment of anxiety experienced by cancer patients. Anxiety that may arise after cancer therapy has been completed is also discussed in this summary.

Overview

Anxiety is a normal reaction to cancer. One may experience anxiety while undergoing a cancer screening test, waiting for test results, receiving a diagnosis of cancer, undergoing cancer treatment, or anticipating a recurrence of cancer. Anxiety associated with cancer may increase feelings of pain, interfere with one's ability to sleep, cause nausea and vomiting, and interfere with the patient's (and his or her family's) quality of life. If left untreated, severe anxiety may even shorten a patient's life.

Persons with cancer will find that their feelings of anxiety increase or decrease at different times. A patient may become more anxious as cancer spreads or treatment becomes more intense. The level of anxiety experienced by one person with cancer may differ from the anxiety experienced by another person. Most patients are able to reduce their anxiety by learning more about their cancer and the treatment they can expect to receive. For some patients, particularly those who have experienced episodes of intense anxiety before their cancer diagnosis, feelings of anxiety may become overwhelming and interfere with cancer treatment. Most patients who have not had an anxiety condition before their cancer diagnosis will not develop an anxiety disorder associated with cancer.

Intense anxiety associated with cancer treatment is more likely to occur in patients with a history of anxiety disorders and patients who are experiencing anxiety at the time of diagnosis. Anxiety may also be experienced by patients who are in severe pain, are disabled, have few friends or family members to care for them, have cancer that is not responding to treatment, or have a history of severe physical or emotional trauma. Central nervous system metastases and tumors in the lungs may create physical problems that cause anxiety. Many cancer medications and treatments can aggravate feelings of anxiety.

Contrary to what one might expect, patients with advanced cancer experience anxiety due not to fear of death, but more often from fear of uncontrolled pain, being left alone, or dependency on others. Many of these factors can be alleviated with treatment.

Description and Cause

Some persons may have already experienced intense anxiety in their life because of situations unrelated to their cancer. These anxiety conditions may recur or become aggravated by the stress of a cancer diagnosis. Patients may experience extreme fear, be unable to absorb information given to them by caregivers, or be unable to follow through with treatment. In order to plan treatment for a patient's anxiety, a doctor may ask the following questions about the patient's symptoms:

  • Have you had any of the following symptoms since your cancer diagnosis or treatment? When do these symptoms occur (i.e., how many days prior to treatment, at night, or at no specific time) and how long do they last?
  • Do you feel shaky, jittery, or nervous?
  • Have you felt tense, fearful, or apprehensive?
  • Have you had to avoid certain places or activities because of fear?
  • Have you felt your heart pounding or racing?
  • Have you had trouble catching your breath when nervous?
  • Have you had any unjustified sweating or trembling?
  • Have you felt a knot in your stomach?
  • Have you felt like you have a lump in your throat?
  • Do you find yourself pacing?
  • Are you afraid to close your eyes at night for fear that you may die in your sleep?
  • Do you worry about the next diagnostic test, or the results of it, weeks in advance?
  • Have you suddenly had a fear of losing control or going crazy?
  • Have you suddenly had a fear of dying?
  • Do you often worry about when your pain will return and how bad it will get?
  • Do you worry about whether you will be able to get your next dose of pain medication on time?
  • Do you spend more time in bed than you should because you are afraid that the pain will intensify if you stand up or move about?
  • Have you been confused or disoriented lately?


Anxiety disorder includes adjustment disorder, panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and anxiety disorder caused by other general medical conditions. Each of these is explained below.

Adjustment Disorder

Adjustment disorder includes behaviors or moods more extreme than expected in a reaction to a cancer diagnosis. Symptoms include severe nervousness, worry, jitteriness, and the inability to go to work, attend school, or be with other people. Adjustment disorder is more likely to occur in cancer patients during critical times of the disease. These include being tested for the disease, learning the diagnosis, and experiencing a relapse of the disease. Many cancer patients can achieve relief from adjustment disorder in several ways, including receiving reassurance from caregivers, exercising relaxation techniques, taking medication, and participating in support and education programs.

Panic Disorder

Patients with panic disorder experience intense anxiety. Patients may suffer shortness of breath, dizziness, rapid heart beat, trembling, profuse sweating, nausea, tingling sensations, or fears of "going crazy." Attacks may last for several minutes or several hours and are treated with medication. Symptoms of panic disorder may be very similar to other medical conditions.

Phobias

Phobias are ongoing fears about or avoidance of a situation or object. People with phobias usually experience intense anxiety and avoid situations that may frighten them. Cancer patients may fear needles. They may also fear small spaces and avoid having tests in confined spaces, such as magnetic resonance imaging (MRI) scans.

Obsessive-Compulsive Disorder

A person with obsessive-compulsive disorder has persistent thoughts, ideas, or images (obsessions) that are accompanied by repetitive behaviors (compulsions). Patients with obsessive-compulsive disorder may be unable to follow through with cancer treatment because they are disabled by thoughts and behaviors that interfere with their ability to function normally. Obsessive-compulsive disorder is treated with medication and psychotherapy. Obsessive-compulsive disorder is rare in patients with cancer who did not have the disorder before being diagnosed with cancer.

Post-Traumatic Stress Disorder

The diagnosis of cancer may cause a person who has previously experienced a life-threatening event to relive the trauma associated with that event. Patients with cancer who have post-traumatic stress disorder may experience extreme anxiety before surgery, chemotherapy, painful medical procedures, or bandage changes. Post-traumatic stress disorder is treated with psychotherapy.

Generalized Anxiety Disorder

Patients with generalized anxiety disorder may experience extreme and constant anxiety or unrealistic worry. For example, patients with supportive family and friends may fear that no one will care for them. Patients may worry that they cannot pay for their treatment, although they have adequate financial resources and insurance. Generalized anxiety disorder may happen after a patient has been very depressed. A person who has generalized anxiety may feel irritable or restless, have tense muscles, shortness of breath, heart palpitations, sweating, dizziness, and be easily fatigued.

Anxiety Disorder Caused by Other General Medical Conditions

Patients with cancer may experience anxiety that is caused by other medical conditions. Patients who are experiencing severe pain feel anxious, and anxiety can increase pain. The sudden appearance of extreme anxiety may be a symptom of infection, pneumonia, or an imbalance in the body's chemistry. It may also occur before a heart attack or blood clot in the lung and be accompanied by chest pain or trouble breathing. A decrease in the amount of oxygen that the blood is able to carry may also make the patient feel as though he or she is suffocating; this can cause anxiety.

Anxiety is a direct or indirect side effect of some medications. Some medications can cause anxiety, while others may cause restlessness, agitation, depression, thoughts of suicide, irritability, or trembling.

Certain tumors may cause anxiety or produce symptoms that resemble anxiety and panic by creating chemical imbalances or shortness of breath.

Treatment


It may be difficult to distinguish between normal fears associated with cancer and abnormally severe fears that can be classified as an anxiety disorder. Treatment depends on how the anxiety is affecting daily life for the patient. Anxiety that is caused by pain or another medical condition, a specific type of tumor, or as a side-effect of medication, is usually controlled by treating the underlying cause.

Treatment for anxiety begins by giving the patient adequate information and support. Developing coping strategies such as the patient viewing his or her cancer from the perspective of a problem to be solved, obtaining enough information in order to fully understand his or her disease and treatment options, and utilizing available resources and support systems, can help to relieve anxiety. Patients may benefit from other treatment options for anxiety, including: psychotherapy, group therapy, family therapy, participating in self-help groups, hypnosis, and relaxation techniques such as guided imagery (a form of focused concentration on mental images to assist in stress management), or biofeedback (a method of early detection of the symptoms of anxiety in order to take preventative action). Medications may be used alone or in combination with these techniques. Patients should not avoid anxiety-relieving medications for fear of becoming addicted. Their doctors will give them sufficient medication to alleviate the symptoms and decrease the amount of the drug as the symptoms diminish.

Post-treatment Considerations

After cancer therapy has been completed, a cancer survivor may be faced with new anxieties. Survivors may experience anxiety when they return to work and are asked about their cancer experience, or when confronted with insurance-related problems. A survivor may fear subsequent follow-up examinations and diagnostic tests, or they may fear a recurrence of cancer. Survivors may experience anxiety due to changes in body image, sexual dysfunction, reproductive issues, or post-traumatic stress. Survivorship programs, support groups, counseling, and other resources are available to help people readjust to life after cancer.




Depression

Depression is a disabling illness that affects about 15% to 25% of cancer patients. This brief summary describes the causes and treatment of depression and risk factors and prevention of suicide in adults and children who have cancer.

Overview

People who face a diagnosis of cancer will experience different levels of stress and emotional upset. Fear of death, interruption of life plans, changes in body image and self-esteem, changes in the social role and lifestyle, and money and legal concerns are important issues in the life of any person with cancer, yet serious depression is not experienced by everyone who is diagnosed with cancer.

There are many misconceptions about cancer and how people cope with it, such as the following: all people with cancer are depressed; depression in a person with cancer is normal; treatment does not help the depression; and everyone with cancer faces suffering and a painful death. Sadness and grief are normal reactions to the crises faced during cancer, and will be experienced at times by all people. Since sadness is common, it is important to distinguish between "normal" levels of sadness and depression. An important part of cancer care is the recognition of depression that needs to be treated. Some people may have more trouble adjusting to the diagnosis of cancer than others. Major depression is not simply sadness or a blue mood. Major depression affects about 25% of patients and has common symptoms that can be diagnosed and treated.

All people periodically throughout diagnosis, treatment, and survival of cancer will experience reactions of sadness and grief. When people find out they have cancer, they often have feelings of disbelief, denial, or despair. They may also experience difficulty sleeping, loss of appetite, anxiety, and a preoccupation with worries about the future. These symptoms and fears usually lessen as a person adjusts to the diagnosis. Signs that a person has adjusted to the diagnosis include an ability to maintain active involvement in daily life activities, and an ability to continue functioning as spouse, parent, employee, or other roles by incorporating treatment into his or her schedule. A person who cannot adjust to the diagnosis after a long period of time, and who loses interest in usual activities, may be depressed. Mild symptoms of depression can be distressing and may be helped with counseling. Even patients without obvious symptoms of depression may benefit from counseling. However, when symptoms are intense and long-lasting, or when they keep coming back, more intensive treatment is important.

Diagnosis

The symptoms of major depression include 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; and constant thoughts of death or suicide. To make a diagnosis of depression, these symptoms should be present 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. There are cancer-related and noncancer-related risk factors.

Cancer-Related Risk Factors:

  • Depression at the time of cancer diagnosis
  • Poorly controlled pain
  • An advanced stage of cancer
  • Other life events that produce stress
  • 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
  • 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, "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: "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 disease since the illness may be causing decreased functioning. In more advanced illness, focusing on despair, guilty thoughts, and a total lack of enjoyment of life is helpful in diagnosing depression.

Medical factors may also cause depression in cancer patients. 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 cancer patients include uncontrolled pain; abnormal levels of calcium, sodium, or potassium in the blood; anemia; vitamin B12 or folate deficiency; fever; and abnormal levels of thyroid hormone or steroids in the blood.

Treatment

Major depression may be treated with a combination of counseling and medications, such as antidepressants. A primary care doctor may prescribe medications for depression and refer the patient to a psychiatrist or psychologist for the following reasons: a physician or oncologist is not comfortable treating the depression (for example, the patient has suicidal thoughts); the symptoms of depression do not improve after 2 to 4 weeks of treatment; the symptoms are getting worse; the side effects of the medication keep the patient from taking the dosage needed to control the depression; and/or the symptoms are interfering with the patient's ability to continue medical treatment.

Antidepressants are safe for cancer patients to use and are usually effective in the treatment of depression and its symptoms. Unfortunately, antidepressants are not often prescribed for cancer patients. About 25% of all cancer patients are depressed, but only about 2% receive medication for the depression. The choice of antidepressant depends on the patient's symptoms, potential side effects of the antidepressant, and the person's individual medical problems and previous response to antidepressant drugs.

St. John's wort (hypericum perforatum) has been used as an over-the-counter supplement for mood enhancement. In the United States, dietary supplements are regulated as foods not drugs. The Food and Drug Administration (FDA) does not require that supplements be approved before being put on the market. Because there are no standards for product manufacturing consistency, dose, or purity, the safety of St. John's wort is not known. The FDA has issued a warning that there is a significant drug interaction between St. John's wort and indinavir (a drug used to treat HIV infection). When St. John's wort and indinavir are taken together, indinavir is less effective. Patients with symptoms of depression should be evaluated by a health professional and not self-treat with St. John's wort. St. John's wort is not recommended for major depression in patients who have cancer.

Most antidepressants take 3 to 6 weeks to begin working. The side effects must be considered when deciding which antidepressant to use. For example, a medication that causes sleepiness may be helpful in an anxious patient who is having problems sleeping, since the drug is both calming and sedating. Patients who cannot swallow pills may be able to take the medication as a liquid or as an injection. If the antidepressant helps the symptoms, treatment should continue for at least 6 months. Electroconvulsive therapy (ECT) is a useful and safe therapy when other treatments have been unsuccessful in relieving major depression.

Several psychiatric therapies have been found to be beneficial for the treatment of depression related to cancer. These therapies are often used in combination and include crisis intervention, psychotherapy, and thought/behavior techniques. These therapies usually consist of 3 to 10 sessions and explore methods of lowering distress, improving coping and problem-solving skills; enlisting support; reshaping negative and self-defeating thoughts; and developing a close personal bond with an understanding health care provider. Talking with a clergy member may also be helpful for some people.

Specific goals of these therapies are:

  • Assist people diagnosed with cancer and their families by answering questions about the illness and its treatment, explaining information, correcting misunderstandings, giving reassurance about the situation, and exploring with the patient how the diagnosis relates to previous experiences with cancer.
  • Assist with problem solving, improve the patient's coping skills, and help the patient and family to develop additional coping skills. Explore other areas of stress, such as family role and lifestyle changes, and encourage family members to support and share concern with each other.
  • When the focus of treatment changes from trying to cure the cancer to relieving symptoms, the health care team will not abandon the patient and family and will maintain comfort, control pain, and maintain the dignity of the patient and his or her family members.


Cancer support groups may also be helpful in treating depression in cancer patients, especially adolescents. Support groups have been shown to improve mood, encourage the development of coping skills, improve quality of life, and improve immune response. Support groups can be found through the wellness community, the American Cancer Society, and many community resources, including the social work departments in medical centers and hospitals.

Considerations for Depression in Children

Most children cope with the emotions related to cancer and not only adjust well, but show positive emotional growth and development. However, a minority of children develops psychologic problems including depression, anxiety, sleeping problems, relationship problems, and are uncooperative about treatment. A mental health specialist should treat these children.

Children with severe late effects of cancer have more symptoms of depression. Anxiety usually occurs in younger patients, while depression is more common in older children. Most cancer survivors are generally able to adapt and adjust successfully to cancer and its treatment. However, a small number of cancer survivors have difficulty adjusting.

Diagnosis of Childhood Depression

The term "depression" refers to a symptom, a syndrome, a set of psychological responses, or an illness. The length and intensity of the response (such as sadness) distinguishes the symptoms from the disorder. For example, a child may be sad in response to trauma, and the sadness usually lasts a short time. However, depression is marked by a response that lasts a long time, and is associated with sleeplessness, irritability, changes in eating habits, and problems at school and with friends. Depression should be considered whenever any behavior problem continues. Depression does not refer to temporary moments of sadness, but rather to a disorder that affects development and interferes with the child's progress.

Some signs of depression in the school-aged child include not eating, inactivity, looking sad, aggression, crying, hyperactivity, physical complaints, fear of death, frustration, feelings of sadness or hopelessness, self criticism, frequent day dreaming, low self-esteem, refusing to go to school, learning problems, slow movements, showing anger towards parents and teachers, and loss of interest in activities that were previously enjoyed. Some of these signs can occur in response to normal developmental stages; therefore, it is important to determine whether they are related to depression or a developmental stage.

Determining a diagnosis of depression includes evaluating the child's family situation, as well as his or her level of emotional maturity and ability to cope with illness and treatment; the child's age and state of development; and the child's self esteem and prior experience with illness.

A comprehensive assessment for childhood depression is necessary for effective diagnosis and treatment. Evaluation of the child and family situation focuses on the child's health history; observations of the behavior of the child by parents, teachers, or health care workers; interviews with the child; and use of psychological tests.

Childhood depression and adult depression are different illnesses due to the developmental issues involved in childhood. The following criteria may also be used for diagnosing depression in children: a sad mood (and a "sad" facial expression in children younger than 6) with at least 4 of the following signs or symptoms present every day for a period of at least 2 weeks: appetite changes, not sleeping or sleeping too much, being too active, or not active enough, loss of interest or pleasure in usual activities, signs of not caring about anything (in children younger than 6); tiredness or loss of energy; feelings of worthlessness, self-criticism, or inappropriate guilt; inability to think or concentrate well; and constant thoughts of death or suicide.

Treatment of Childhood Depression

Individual and group counseling are usually used as the first treatment for a child with depression, and are directed at helping the child to master his or her difficulties and develop in the best way possible. Play therapy may be used as a way to explore the younger child's view of him- or herself, the disease, and treatment. From the beginning, a child needs help to understand, at his or her developmental level, the diagnosis of cancer and the treatment involved. A doctor may prescribe medications, such as antidepressants, for children. Some of the same antidepressants prescribed for adults may also be prescribed for children.

Evaluation and Treatment of Suicidal Cancer Patients

The incidence of suicide in cancer patients may be as much as 10 times higher than the rate of suicide in the general population. Passive suicidal thoughts are fairly common in cancer patients. The relationships between suicidal tendency and the desire for hastened death, requests for physician-assisted suicide, and/or euthanasia are complicated and poorly understood. Men with cancer are at an increased risk of suicide compared with the general population, with more than twice the risk. Overdosing with pain killers and sedatives is the most common method of suicide by cancer patients, with most cancer suicides occurring at home. The occurrence of suicide is higher in patients with oral, pharyngeal, and lung cancers and in HIV-positive patients with Kaposi's sarcoma. The actual incidence of suicide in cancer patients is probably underestimated, since there may be reluctance to report these deaths as suicides.

General risk factors for suicide in a person with cancer include a history of mental problems, especially those associated with impulsive behavior (such as, borderline personality disorders); a family history of suicide; a history of suicide attempts; depression; substance abuse; recent death of a friend or spouse; and having little social support.

Cancer-specific risk factors for suicide include a diagnosis of oral, pharyngeal, or lung cancer (often associated with heavy alcohol and tobacco use); advanced stage of disease and poor prognosis; confusion/delirium; poorly controlled pain; or physical impairments, such as loss of mobility, loss of bowel and bladder control, amputation, loss of eyesight or hearing, paralysis, inability to eat or swallow, tiredness, or exhaustion.

Patients who are suicidal require careful evaluation. The risk of suicide increases if the patient reports thoughts of suicide and has a plan to carry it out. Risk continues to increase if the plan is "lethal," that is, the plan is likely to cause death. A lethal suicide plan is more likely to be carried out if the way chosen to cause death is available to the person, the attempt cannot be stopped once it is started, and help is unavailable. When a person with cancer reports thoughts of death, it is important to determine whether the underlying cause is depression or a desire to control unbearable symptoms. Prompt identification and treatment of major depression is important in decreasing the risk for suicide. Risk factors, especially hopelessness (which is a better predictor for suicide than depression) should be carefully determined. The assessment of hopelessness is not easy in the person who has advanced cancer with no hope of a cure. It is important to determine the basic reasons for hopelessness, which may be related to cancer symptoms, fears of painful death, or feelings of abandonment.

Talking about suicide will not cause the patient to attempt suicide; it actually shows that this is a concern and permits the patient to describe his or her feelings and fears, providing a sense of control. A crisis intervention-oriented treatment approach should be used which involves the patient's support system. Contributing symptoms, such as pain, should be aggressively controlled and depression, psychosis, anxiety, and underlying causes of delirium should be treated. These problems are usually treated in a medical hospital or at home. Although not usually necessary, a suicidal cancer patient may need to be hospitalized in a psychiatric unit.

The goal of treatment of suicidal patients is to attempt to prevent suicide that is caused by desperation due to poorly controlled symptoms. Patients close to the end of life may not be able to stay awake without a great amount of emotional or physical pain. This often leads to thoughts of suicide or requests for aid in dying. Such patients may need sedation to ease their distress.

Other treatment considerations include using medications that work quickly to alleviate distress (such as, antianxiety medication or stimulants) while waiting for the antidepressant medication to work; limiting the quantities of medications that are lethal in overdose; having frequent contact with a health care professional who can closely observe the patient; avoiding long periods of time when the patient is alone; making sure the patient has available support; and determining the patient's mental and emotional response at each crisis point during the cancer experience.

Pain and symptom treatment should not be sacrificed simply to avoid the possibility that a patient will attempt suicide. Patients often have a method to commit suicide available to them. Incomplete pain and symptom treatment might actually worsen a patient's suicide risk.

Frequent contact with the health professional can help limit the amount of lethal drugs available to the patient and family. Infusion devices that limit patient access to medications can also be used at home or in the hospital. These are programmable, portable pumps with coded access and a locked cartridge containing the medication. These pumps are very useful in controlling pain and other symptoms. Some pumps can give multiple drug infusions, and some can be programmed over the phone. The devices are available through home care agencies, but are very expensive. Some of the expense may be covered by insurance.

Effects of suicide on family and health care providers

Suicide can make the loss of a loved one especially difficult for survivors. Survivors often have reactions that include feelings of abandonment, rejection, anger, relief, guilt, responsibility, denial, identification, and shame. These reactions are affected by the type and intensity of relationship; the nature of the suicide; the age and physical condition of the deceased; the survivor's support network and coping skills; and cultural and religious beliefs. Survivors should have help during this period of grieving. Mutual support groups can lessen isolation, provide opportunities to discuss feelings, and help survivors find ways to cope.

The reactions of health care providers to the suicide are similar to those seen in family members, although caregivers often do not feel they have the right to express their feelings.

Assisted Dying, Euthanasia, and Decisions Regarding End of Life

Respecting and promoting patient control has been one of the driving forces behind the hospice movement and right-to-die issues that range from honoring living wills to promoting euthanasia (mercy killing). These issues can create a conflict between a patient's desire for control and a physician's duty to promote health. These are issues of law, ethics, medicine, and philosophy. Some physicians may favor strong pain control and approve of the right of patients to refuse life support, but do not favor euthanasia or assisted suicide. Often patients who ask for physician-assisted suicide can be treated by increasing the patient's comfort, relieving symptoms, thereby reducing the patient's need for drastic measures. Patients with the desire to die should be carefully evaluated and treated for depression.

Suicide and Children

Suicide is as rare among adolescents who have no other mental disorders as it is among adults. The adolescent often believes that his or her disease is outside the realm of control, and is in the hands of God or some other force. Refusing treatment is not a way of attempting suicide, but comes from his or her belief that fate, luck, or God determines life and death.

In the general population, about 2,000 adolescents in the United States die by suicide each year. Suicide continually ranks as the second or third leading cause of death of persons between the ages of 15 and 34 years old. Children are less prone to suicide before puberty due to immature reasoning capabilities that make planning and carrying out suicide difficult. The suicide rate in young people has more than doubled during the period from 1956 to 1993. This increasing suicide rate has been blamed on the increase of adolescent alcohol abuse. Chronic and acute illnesses were not major causes of suicide in the young. The suicide rate for male adolescents is four times as high as the rate for females. The suicide rate for white adolescents is about twice as great as the rate for African-Americans and Hispanics. Little is known about the occurrence of thoughts of suicide and attempts in children with cancer.

The risk factors for the general population of children include:

  • Biologic factors: Family history of mental problems such as depression, schizophrenia, alcoholism, drug dependence, and conduct disorders. Genetic predisposition to low levels of serotonin is associated with depression.
  • Predisposing life events: An early family history of abuse by a parent; negative life event such as loss of a parent; childhood grief; and disturbed, hostile relationships in the family. Many other social problems and negative life events do not seem to cause suicidal behavior.
  • Social factors: The very nature of adolescence itself with its desire to experiment with drugs and alcohol. Conflict or confusion about sexual orientation can be a factor in adolescent suicide. Also, characteristics such as perfectionism, impulsiveness, inhibition, and isolation all can lead to thoughts of suicide.
  • Mental problems: Ninety five percent of young people who commit suicide have a mental disorder. These are usually major depression, schizophrenia, alcoholism, drug dependence, and conduct disorder. However, most children with mental problems do not commit suicide.
  • Contagion: An expression that describes the phenomenon of young people identifying with others who have committed suicide. Some young people who are vulnerable may copy suicidal behavior. Friends of a cancer patient who has committed suicide should be offered support and counseling.
  • Deadly weapons available: A gun in the house can allow suicide to occur.
  • Motivating events: The diagnosis of cancer can cause a person at risk to attempt suicide. Usually a mental disorder, other life stresses, an upsetting event such as a failure in school, or life-threatening disease such as cancer is already present.


Some adolescent cancer survivors may be overwhelmed by feelings of hopelessness. This may lead to thoughts of suicide. Suicide is treated by the careful evaluation of the child with cancer and his or her family. The multiple factors that can make a child's life unbearable need to be examined. Suicide prevention must include individual evaluation; referral to the correct health professionals; treatment with medications; and both individual counseling and family therapy.






The information on this page was obtained from the National Cancer Institute. The National Cancer Institute provides accurate, up-to-date information on many types of cancer, information on clinical trials, resources for people dealing with cancer, and information for researchers and health professionals.

The National Cancer Institute is in no way affiliated with the Mary Stolfa Cancer Foundation.

The information on this web site is provided for general information only. It is not intended as medical advice, and should not be relied upon as a substitute for consultations with qualified health professionals who are familiar with your individual medical needs. The MSCF disclaims all obligations and liabilities for damages arising from the use or attempted use of the information, including but not limited to direct, indirect, special, and consequential damages, attorneys' and experts' fees and court costs. Any use of the information will be at the risk of the user.





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