Don’t Let Depression Decide for You

By Celia Gittelson,

Tuesday, January 20, 2015

Depressed Woman

People with cancer who are depressed can have difficulty making appropriate treatment decisions. MSK psychiatrist Mary Jane Massie discusses the problem and what can be done to help.

Writer William Styron described his experience of depression as being trapped “in a storm of murk,” a powerful characterization of the way a person feels when suffering from this condition — the sense of being mired in a dense fog with no way out.

Not only can depression impose feelings of deep sadness, dread, or hopelessness, it can also inhibit other processes in the brain. One of these is the ability to make choices. And if you have cancer, untreated depression can be particularly dangerous if it impairs your ability to make informed decisions.

What’s Normal, What’s Not

It’s natural that anyone receiving a cancer diagnosis will be thrown for a loop. Fear, sadness, and anger are all normal reactions. Studies have shown, though, that more than half of people with cancer manifest remarkable resilience. More often than not, they adapt to their “new normal” within a few days or weeks and remain emotionally resilient throughout treatment and thereafter — despite experiencing intermittent periods of depressed mood or anxiety.

However, a significant subgroup is vulnerable to unrelenting and sometimes crippling distress. And it has long been known that depression in a patient with a serious illness such as cancer, often coupled with anxiety, may render that person unable to hear what his or her doctor recommends, explains Memorial Sloan Kettering psychiatrist Mary Jane Massie.

Depression may in fact be the most immediately life-threatening of all a person’s medical conditions if it gives rise to faulty decision-making when considering or complying with treatment recommendations. “Depressed patients often can’t or refuse to adhere to treatment,” Dr. Massie elaborates. “They may feel it’s futile, that they’re going to die anyway, or may think ‘I’m already a burden on my family with my depression, why make it worse?’”

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Double Trouble

Those at highest risk of long-lasting depression come to a cancer diagnosis already depressed or having experienced depression in the past. The myriad of issues they may be facing  — and be unable to cope with — include fears of becoming disabled or dependent,  guilt, and loss of self-esteem or social supports, Dr. Massie says. Such feelings are often magnified by the distorted thinking brought on by depression and, along with an inability to concentrate and clearly weigh one’s options, can result in a wish not to pursue potentially life-saving therapies.

Indeed, depression is of such clinical importance that it was the subject of an American Society of Clinical Oncology special article published in November 2014 in the Journal of Clinical Oncology that Dr. Massie and Jimmie C. Holland, former Chair of MSK’s Department of Psychiatry and Behavioral Sciences, co-authored. Entitled “Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults with Cancer,” it established guidelines for evaluating patients for symptoms of depression and anxiety throughout the cancer treatment journey.

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How Are You Doing?

Depression often goes undetected in people with cancer. It’s understandable: The disease takes center stage and all else becomes background noise. So, says Dr. Massie, one of the first orders of business is to screen everyone. “Begin at the time of the initial cancer diagnosis,” she counsels, and then continue routinely throughout treatment.

“I’d hope that every oncologist would ask at every visit, ‘How are you doing today?’” Dr. Massie continues. “Of course, he or she is also monitoring for other changes in a patient’s health, but right up there at the top of the list should be the ‘How are you doing?’ question, looking for signs of depression.”

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Help Is Out There

A range of psychiatric medications is available for the treatment of depression and anxiety and can be tremendously useful in increasing an individual’s overall functioning.

Antidepressants are a mainstay of treatment and many of the newer drugs have a variety of uses. “Some drugs are more alerting and some more sedating,” says Dr. Massie. “So a person experiencing agitation or insomnia will likely benefit from one of the more sedating drugs, while a person who’s experiencing apathy or lethargy as a consequence of depression may do better with one of the more alerting drugs.”

Modern antidepressant and antianxiety medications can also be useful for the alleviation of pain related to cancer treatment or depression and may be used alone or in combination with other drugs.

Dr. Massie is also a proponent of talk therapy. “A psychiatrist trained in working with people who have cancer can help you think through your options and decisions, whether treatment-related or not. We want to do everything we can to get our patients into a position where they can live as natural and normal a life as possible while undergoing treatment — with the ultimate goal of sending them on their way healthier and happier than when we first met!”

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