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Depression

Introduction

  • Some degree of sadness is to be expected among patients and among family members caring for a loved one with cancer. This can come from the many changes that are imposed by the illness and the unknown future that lies ahead.

  • Clinical depression is different from the sadness that most families experience.

  • It is critical to assess accurately whether the individual is suffering from clinical depression. Depression is a treatable illness that can be managed by medication and/or psychotherapy.

  • When assessing for depression in people with cancer, it is important to remember that many of the symptoms of depression can also be symptoms of cancer or cancer treatment.

  • There is considerable evidence that a depressive disorder in the person with cancer can lead to greater distress, decreased functioning and decreased ability to adhere to medical recommendations1.

  • The AHCPR guidelines state that several factors predispose cancer patients to develop depressive disorders. These include: social isolation, recent losses, a tendency to pessimism, socioeconomic pressures, a history of mood disorder, alcohol or substance abuse, previous suicide attempt(s), or poorly controlled pain.


Assessment

The American Cancer Society states that if five or more of the following symptoms last for two weeks or longer, or are severe enough to interfere with normal functioning, the individual should be evaluated by a qualified mental health professional:

  • persistent sad or "empty" mood
  • loss of interest or pleasure in ordinary activities
  • decreased energy, fatigue, being "slowed down"
  • sleep disturbances (insomnia, early waking or oversleeping)
  • eating disturbances (loss of appetite or overeating)
  • difficulty concentrating, remembering, making decisions
  • feelings of guilt, worthlessness, helplessness
  • irritability
  • excessive crying
  • chronic aches and pains for no apparent reason
  • thoughts of death or suicide, suicide attempts


Interventions

  • If depression is suspected, contact a mental health professional to assess for clinical depression and to determine whether medication and/or psychotherapy would be appropriate.

  • Review medications to assess for depressive side effects

  • Instruct the individual to avoid alcoholic beverages, as they have a depressive effect

  • Provide a supportive atmosphere in which the individual feels comfortable expressing his or her feelings to you. For people who are experiencing normal sadness, discussions about the meaning of the illness or a purposeful review of the role that the ill person played in their relationship may help caregivers identify and clarify their feelings.

  • Encourage the individual to participate in support groups, or to contact their priest, minister, or rabbi.

  • Encourage prayer or other spiritual support, if this is of comfort to the individual

  • Do not force anyone to talk if they are not ready, however, reinforce that depression is not a sign of weakness and they should not be embarrassed to talk about their feelings

  • Don't feel that you must cheer the person up in order to be helpful

  • Don't feel that expressing or acknowledging feelings will make the caregiver feel worse. It is important to validate the burden that these feelings cause.

  • Recognize that depression often makes people feel unable to take action. Therefore, you may recommend a referral or a support group and find that the caregiver does not follow through with your recommendation. Try to facilitate follow-through... Arrange for a third party to provide transportation...encourage the caregiver to implement a recommendation while you are present in the home.

  • Encourage hospice volunteers or other volunteer home visitors to visit with the caregiver as well as the patient. Frequently, depression in the caregiver drives other members of the their support system away. Volunteer visitors play an important role in reducing the isolation that is caused by and contributes to their depression.

  • Remind the individual that treatment of depression may take weeks to months to notice improvement. It may also recur at some later date, but having experienced it, the individual will be able to identify and treat it earlier.

  • While suicide is less common than many people think, thoughts and discussion about suicide must be taken seriously. Try to determine if thoughts and discussion about suicide are motivated by uncontrolled symptoms in the patient, such as pain.


Much of the preceding information has been derived from materials from the American Cancer Society, 1599 Clifton Road NE, Atlanta, GA, 30329


1 Agency for Health Care Policy and Research (1993) Depression in Primary Care: Volume 1, Detection and Diagnosis. Clinical Practice Guideline Number 5. US Department of Health and Human Services. AHCPR publication no. 93-0550.





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