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Crawling out of the deep hole of cancer depression

A University of Michigan Health Minute update on important health issues
U-M program addresses the emotional side of cancer diagnosis, treatment --added 4/1/05

Ann Arbor - For Bill Howe, cancer was a deep hole that went far beyond the physical effects of treatment.

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“With the combination of the treatments and the emotional rollercoaster that you ride when this happens to you, you get into a situation where you’re very confused, you’re lost, your anger is prevalent. You want answers and you can’t get them,” said Howe, 58, who was diagnosed with prostate cancer in 2001.
“It came to a point where I just couldn’t do it anymore. That was the phrase I used: I just can’t do this anymore. And I was probably the worst I’ve ever seen myself in being able to cope with it. It just seemed like it all tumbled down upon my shoulders and I couldn’t see the daylight. It’s like crawling out of a deep hole. I couldn’t do it,” Howe said.

His oncologist referred him to the PsychOncology Program at the University of Michigan Comprehensive Cancer Center. The program is available to patients and families to help them deal with the emotional aspects of cancer – an area that’s often overlooked as patients and their doctors focus on a wide range of physical side effects.

Increasingly, health care providers are realizing the many mental health issues involved in a cancer diagnosis. It starts with the adjustment of hearing a diagnosis and understanding what it means and continues through the grueling nature of most cancer treatments and the uncertainty and worry that the cancer will come back or spread.

“Cancer itself can cause people to become anxious or depressed. The treatments can contribute to mood changes, adjustment problems, even delirium in some cases, and so there’s a wide range of mental health issues that can affect patients,” said Michelle Riba, M.D., director of the PsychOncology Program at the U-M Comprehensive Cancer Center and professor of psychiatry at U-M Medical School.

She said it’s particularly important to consider a history of mental health problems, including substance abuse, anxiety or depression, that may return with the stress of cancer.

“When people are diagnosed with cancer, it’s not a clean slate. The cancer is added on to past problems,” said Riba, who is also president of the American Psychiatric Association.

Some cancers have a particular effect on emotions: some brain tumors, pancreatic cancer and lung cancer tend to be the most debilitating emotionally. Patients with those types of cancer often have more difficulty with depression and anxiety than patients with other types of cancer. Researchers suspect biochemical factors and the location of the tumor somehow impact the emotions.

Cancer treatment can also induce emotional difficulties. For example, high dose steroids that are often given to combat chemotherapy side effects are well known to cause depression, anxiety or even psychosis.

“Often the symptoms of the depression or anxiety are very similar to the problems that patients have with the cancer itself, its treatment or its side effects. So not having an appetite or being quite fatigued may be related to the cancer itself, but also can be related to having depression. So it’s sometimes very difficult to tease out,” Riba said.

For Howe, memory loss and difficulties with mental tasks due to his chemotherapy and radiation treatment contributed to his depression and anxiety.

“It’s almost like being outside yourself and looking at that person and not recognizing who he is. You’re extremely tired. All you want to do is sleep. You’re looking for answers and no one seems to have them. Because there aren’t any. Because you’re going through treatment, and we don’t know how effective that treatment’s going to be until we’ve completed it four years later,” Howe said.

Working with Riba, Howe’s cancer treatment now includes medication to treat his depression and therapy to help him dig out of that deep hole. The PsychOncology clinic at U-M allows patients to schedule appointments that coincide with their visits to their oncologist. The clinic is located in the U-M Cancer Center. Specialists there work with individuals, couples or families, and offer one-on-one counseling or group therapy.

“I’m doing better,” Howe said. “It has been a long road and it will continue to be a long road because you find out that while cancer treatment gives you life – which is a wonderful, wonderful thing – it also takes things from you. It takes your mental sharpness; your memory loss is more prevalent; you don’t have the abilities you once had. And it is a long haul getting back to where you were.”

Recognizing signs of distress

The National Comprehensive Cancer Network, a coalition of 19 comprehensive cancer centers across the country, including U-M, recently released guidelines to help doctors and patients recognize distress in cancer treatment. Riba was among the experts who served on the panel that developed these guidelines. The guidelines include these signs that distress is becoming excessive:

• Feeling overwhelmed by fear to the point of panic or an overpowering sense of dread.
• Feeling so sad that you think you cannot go through treatment.
• Unusual irritability and anger.
• Inability to cope with pain, fatigue and nausea.
• Poor concentration, fuzzy thinking and sudden memory problems.
• Difficulty making decisions.
• Wondering if there is any point in going on.
• Constant thoughts about cancer or death.
• Family conflicts and issues that seem impossible to resolve.
• Problems sleeping or eating.
• Questioning faith and religious beliefs that once seemed comforting.
• Feeling worthless and useless.
• Increased vulnerability

Events or experiences from the past may make some people more vulnerable to cancer-related depression or distress. Triggers include:

• A relative who died from cancer.
• Recent loss of a close friend or relative.
• History of depression or suicidal thoughts.
• Reliving a painful event from the past that seems unrelated to your current situation.
• Thoughts of harming yourself or others.

Resources:

Written by: Nicole Fawcett

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