Cancer patients often get depressed simply because having cancer can be a depressing experience.
If you are dealing with cancer, there are many reasons that you may feel depressed from time to time, or at least feel in danger of becoming depressed. Cancer confronts us with our mortality and all of the fears and losses associated with it. It can turn your world upside down, disrupting your life and threatening the roles, purposes, and goals that give you meaning and satisfaction. Cancer therapies may have debilitating side effects and in some cases may cause irreparable damage to your body. Cancer affects not only you but also your loved ones, and this causes you additional emotional distress.
Many cancer patients go through episodes of depression. Depression makes your entire experience with cancer more difficult, weakens your resilience, and may hamper your overall adjustment. It also can undermine your will to live and compromise the courage, fortitude, and determination that you need to face cancer and to endure the necessary medical treatments.
Depression is the exact opposite of what you need: energy and stamina, a vision of a brighter future, hope that inspires and sustains you, and the motivation and commitment to travel through the arduous road of cancer therapy. Depression is therefore a serious threat for anyone dealing with cancer. Fortunately, you can protect yourself from depression, and if it does occur, there are effective remedies for it.
The Nature of Depression
Most of us have been depressed at some time and know what it feels like. The most common complaints are loss of interest in things you used to enjoy (even a simple pleasure, such as listening to your favorite music, could lose its appeal to you); feeling sad, blue, or down in the dumps, and being tearful or crying easily; and feeling depleted of energy and overcome with a paralyzing fatigue.
On some days, a depressed person may feel too drained or apathetic to get out of bed in the morning. You might feel pessimistic and hopeless, begin to welcome death as a relief, and think of suicide. Depression can cause you to feel worthless and guilty, sometimes because of the self-loathing you have developed because of being depressed. Some of the mental problems that accompany depression include difficulty concentrating, difficulty making decisions, and problems with memory. Some of the physical complaints include loss of appetite and libido, sleep disturbances, headaches, and digestive problems.
Causes of Depression
Depression can have psychological or biochemical causes. The psychological causes arise from experiences and events that have a depressing effect; the biochemical (or clinical) causes involve imbalances in the neurochemistry of the brain. Regardless of cause, depression is associated with biochemical change in the brain.
Life experiences may cause depression when they carry certain meanings for the person involved. For example, someone who was abused as a child might conclude that they are undeserving of love or a happy life. Thoughts and feelings of being unworthy, whether conscious or unconscious, can then lead to depression. Other thoughts that commonly underlie depression involve the sense of being helpless, hopeless, and a victim. These thoughts and feelings have their origin in traumatic events in the person’s life (although the person may not remember these events). Not only do these events cause depressing thoughts, they can also bring about a biochemical imbalance in the brain, and this imbalance contributes to the depression.
Most of the times that you are depressed you can identify what you are depressed about or are able to identify depressing thoughts (e.g., “Nothing will make a difference”). However, sometimes depression seems to come out of the blue. People have “come down” with depression in ways that feel similar to coming down with the flu, and they may not be aware of why they are depressed. This is because the psychological factors are unconscious or because the depression is caused solely by changes in the neurochemistry of the brain.
Cancer and Depression
Cancer patients often get depressed simply because having cancer can be a depressing experience. However, there is usually more to it than that. Most cancer patients are not clinically depressed. To varying degrees, they are frightened and upset, but this is not depression. When cancer causes depression, there are psychological or biological reasons for it. These causes are understandable, and they are treatable.
The experience of cancer can cause depression because of the various meanings that the illness takes on as a result of the circumstances or psychological background in which it occurred.
Cancer happens to you as a person, not just to your body. You therefore experience it as part of your personal life. The personal issues, themes, perceptions, and feelings that are embedded in your own personal history color your experience of cancer, giving it a certain meaning and feeling or tone.
The clearest example is seen in the reactions to the diagnosis of cancer in people of various ages. In general, cancer patients in their thirties experience a feeling of incompleteness about their life and a strong emotional investment in a long future; to them, the cancer may feel like a threat to that future and to all the goals and purposes that it holds. Patients in their eighties, on the other hand, generally bring some sense of life completion to their experience of cancer, along with an awareness that their future is relatively short; to them, the same cancer may feel more acceptable because of the long life they already have enjoyed.
Of course, chronological age is not the sole influence on how you experience having cancer or whether you become depressed. The following examples illustrate other ways that your psychological context can contribute to depression.
The feeling of sadness (for yourself and loved ones) evoked by a cancer diagnosis is not itself depression, but if it becomes magnified by other sorrows in your life, it can become depression. In this case, a sorrowful life history before your cancer is the context in which the cancer is experienced. The cancer can represent a kind of crowning blow to a long history of abuse, misfortune, or frustration. It can tap into or reactivate many old feelings. The depression that emerges stems partly from having cancer, but it also grows out of one’s personal life history and its resulting emotional baggage.
Suppose you had recently achieved an important life goal or were on the verge of doing so. Perhaps you had struggled for years to achieve this goal. Then, on the heels of this important accomplishment, you are diagnosed with cancer. You could therefore feel that you were being thwarted, that the deck was stacked against you, or that you were having to pay a price for your ambition. These are the meanings that cancer could hold for you—derived from the context in which it occurred—and they can cause depression.
The medical treatment for cancer cannot help but cause some degree of physical suffering and damage to your body. The optimal goal of treatment, of course, is to restore your body to health, but this comes at some price. Sometimes the price is severe (such as a mastectomy, head or neck surgery, bone marrow transplant, or skin damage from radiation therapy). Different patients feel differently about the bodily effects of cancer treatments, and one response is sometimes depression. Our feelings about ourselves are to some degree dependent upon our appearance and our physical abilities. When these are compromised by cancer, the loss that we suffer (sometimes to our self-esteem, sometimes to our role and identity) can be deeply depressing.
Our culture often assumes that what happens to a person is somehow linked to what that person deserves. Unfortunately, this assumption, which is often very subtle, can affect a cancer patient. When things are going well for us, we tend to assume that we are doing something right and deserve our good fortune. Misfortune—such as cancer—may make us think that we were not so deserving of our good fortune after all. It is not uncommon, therefore, for cancer patients to wonder where they went wrong. Some patients have felt that things were going too well for them, that their life was too easy, or that they were enjoying more happiness than most people, and that cancer was a way of balancing things out. One woman said of her cancer: “It’s all of my repressed resentment and bitterness coming out.” Another patient felt that it was an expression of his self-hatred. One referred to it as “a pathetic attempt for the attention I’ve never had.” Such ideas can cause depression.
As already mentioned, there are also biological causes of depression in cancer patients. The emotional consequences of cancer can bring about biochemical changes in the brain. Biochemical changes can also be caused by chemotherapy drugs, hormonal treatments, anti-inflammatory drugs, pain medication, and radiation therapy.
If you are depressed, it does not necessarily mean that you are not coping or adjusting as you should. It often is important and psychologically healthy for underlying feelings to emerge, as this may provide an opportunity for you to confront and work through the emotional traumas from past years.
Whatever the cause, depression is dangerous, especially to your quality of life and your will to live. There are steps you can take to alleviate it.
What You Can Do to Protect Yourself
There are four important ways to protect yourself from depression when you are dealing with cancer:
- Try to become aware of your emotions, and then acknowledge and express these emotions with someone you feel close to. Depression often results from the suppression of painful and upsetting emotions. Research has shown that cancer patients who openly express their feelings and obtain support from others are much less likely to become depressed.
- Maintain close connections and frequent contact with your loved ones and reach out for their support. Studies have demonstrated that interpersonal support is a strong buffer against feelings of isolation and depression.
- Become an active participant in fostering your physical and emotional well-being. Discuss the treatment options with your doctors so that you are informed and can fully embrace the treatment plan, and consider supplemental approaches as well (such as acupuncture, better nutrition, herbal medicine, meditation, and guided imagery). Your active involvement in your recovery will help to counter the feelings of helplessness and passivity that often characterize depression.
- Try to obtain as much exercise as possible. The physiological and mental benefits of exercise help to offset the depressing effect of a serious illness. One reason for this is that exercise increases the brain levels of endorphins, which are natural mood elevators (see Chapters 32 and 33 on exercise and massage.)
What to Do about Depression
If you become depressed, try to identify what is bothering you. You might make a list of these problems and ways that you could address them. Discuss these problems and emotions with a relative or close friend.
Depression often results from suppressing our emotions, depriving them of the discharge they need. For example, when depression persists long after the loss of a loved one, it is often because the person’s grief has not been adequately expressed. One theory is that un-expressed emotions build up internally and cause depression; another is that the mental energy required to contain such emotions results in the kind of mental fatigue and lethargy characteristic of depression.
It is common to be unaware of what you are depressed about. You might feel that you have no good reason for being depressed, especially because others have far worse problems or because you are grateful for the many blessings you have enjoyed. Try to push yourself beyond that: give yourself the benefit of the doubt—that you have legitimate reasons for your depression—and do some soul-searching to find out what these reasons are. Think about the many ways that cancer can cause depression, as discussed above.
Think especially about your life as a whole, and about the disappointments and sorrows that you have encountered along the way. These may be affecting you now more than you realize. Whatever you come up with in this self-exploration, talk about it with someone you feel especially close to, even if you think you are being foolish, shallow, or self-centered. Permit yourself to feel what you are feeling, honor your reasons for feeling it, and confide in someone about it. Even writing about these matters in a journal can have a relieving effect.
In this process, you might also think about why it is difficult for you to express your feelings. One common reason is not wanting to bother others with your feelings and needs. Some people have difficulty confiding in others because of an underlying belief that they cannot or will not be comforted by doing so. Confiding therefore seems like a setup for more letdown and hurt. Perhaps you let your parents know when something was bothering you, but they did not respond with the comfort or support you needed. Such experiences, over the course of your childhood, could cause you to feel that there was nothing to be gained by voicing your feelings, and that doing so only made you feel worse. While these fears are understandable, it is important to recognize that there is surely someone in your life now (a relative or close friend, a minister or rabbi, a doctor, a nurse, a therapist) who would support you in what you are going through.
Another aspect of depression is that it may cause you to withdraw from others and to turn inward. This can make it all the more difficult to confide in others about your feelings and to obtain the support you need. A vicious circle can set in, wherein a person becomes depressed, withdraws, and therefore has no emotional outlet or personal support and becomes even more depressed. It is essential that you break out of this cycle by finding some way of reaching out for help. If necessary, circle this paragraph, leave it for someone who cares about you to see, and write “Help me” in the margin.
Depression often involves feelings of despair, bitterness, or lack of meaning, resulting in the painful cry of “Why me?” that often arises when someone is subjected to severe suffering. Your religion or spirituality can be a source of meaning and comfort for you, offering a perspective that can soothe the emotional anguish and mental torment that cancer sometimes causes.
Treatment for Depression
Often, a mental health professional provides the best help for depression. Research has shown that psychotherapy is an effective treatment for depression in the majority of cases. A therapist will help you to talk about difficult feelings and will create an emotionally safe environment in which to do so. He or she will also help you to explore all the factors that are contributing to your depression, including those that you may not be aware of. You will learn ways of mastering the thoughts that cause depression. In general, your therapy will consist of working through your depression and the life experiences that are related to it. It will not take your cancer away, and you may still feel upset and worried, but you will no longer be stuck in the deep, dark hole of depression.
Antidepressant medication is warranted in many cases, especially in combination with psychotherapy. The best known of these involve the chemical serotonin, one of the main neurotransmitters. When a neural impulse reaches the end of a nerve cell in the brain, it releases serotonin in the junction (called the synapse) connecting this cell to the next, and this enables the impulse to be transmitted from one cell to the other. Sometimes, the nerve cell sending the signal reabsorbs the serotonin too quickly, and an insufficient amount is left in the junction for the impulse to be transmitted effectively. This phenomenon is apparently associated with the experience of depression.
It is interesting that the mental slowness or lethargy of depression may reflect the state of the brain when serotonin levels are too low. Some antidepressants, called selective serotonin re-uptake inhibitors (SSRIs), block the reabsorption of serotonin, and thereby relieve the symptoms of depression.
There are other types of antidepressant medication besides the SSRIs, and each of these works a little differently. Your physician or psychiatrist will prescribe the best medication for your individual situation. Still, it may take some trial and error to find the medication that works best for you and has the fewest side effects. It may take weeks for some antidepressants to reach their full potential.
The symptomatic relief provided by an antidepressant may be a godsend to a severely depressed person, even though it does not address what the person is depressed about. This relief is often essential in order for the person to even consider ways of addressing the psychological aspects of depression. Research has shown that the best treatment for depression, in many cases, is a combination of emotional support, psychotherapy, and antidepressant medication.
Steps to Overcoming Depression
The depression that stems from cancer and its treatments can make you feel that you can’t go on and that it’s not worth the effort. However, there are effective ways of combating and overcoming this depression:
- Do not blame yourself for being depressed.
- Identify what you are depressed about.
- Confide in someone you feel close to.
- Express your emotions.
- Engage in problem solving.
- Become an active participant in recovery efforts (do not give in to helplessness).
- Do things that enhance self-esteem.
- Exercise as much as possible.
- Talk with your minister or rabbi.
- Deepen your faith or spirituality (through prayer, reading, and meditation).
- Obtain help from a therapist.
- Explore antidepressant medication.
Andrew Kneier, Ph.D.
Andrew Kneier, Ph.D. is a clinical psychologist who specialized over the course of his career in helping patients and families touched by cancer. Most of this work was done at the University of California, San Francisco, Comprehensive Cancer Center where he was the only clinical psychologist for many years. In a number of cancer clinics, he was an integral part of the team and met with all new patients as a routine part of the program of care. More He also worked with hundreds of patients in in-depth psychotherapy and led ongoing support groups for patients with colon cancer, prostate cancer, melanoma, and for husbands whose wives had cancer. All told, he met with over 7500 patients during his full time career. He now works part time with patients through the Sierra Nevada Comprehensive Cancer Center in Grass Valley, California.
Dr. Kneier (pronounced “near”) became a cancer psychologist after living through a serious cancer “scare” that occurred in his late twenties. Every three months scans were done to look for tumors in his chest or abdomen. A therapist helped him cope with the fears and depression that occurred during this difficult time. Once it was determined that it was only a scare (not the real thing) he changed careers with the aim of becoming a therapist to help others as he had been helped. Five years later to obtained his doctorate from the California School of Professional Psychology in Berkeley, CA.
Before this career change, he was on the road to becoming a professor of religious studies through the University of Chicago Divinity School. His interest in religious scholarship grew during his three years as a member of the Christian Brothers and his subsequent study of theology at the University of San Francisco, where he obtained baccalaureate and masters degrees. He feels his background in this area has helped him be attuned to the religious or spiritual questions that can come with a life-threatening disease.