Coping with Depression

Short-term sadness, loss of interest in life or unhappiness is normal when one is diagnosed to have cancer. However, if the above emotions affect your daily life or cause distress, make you feel worthless, affect your sleep or eating habits, and you no longer enjoy the activities you used to enjoy, you may already be suffering from depression. 

If you experience multiple symptoms listed below, and they persist for more than 2 weeks, affecting your normal functioning such as work and social relationships, then there may be signs of depression. You may need to seek help from your medical team. 

Loss and felling helpless is the most common cause of mild depression and can lead to moderate (irritability), or even serious depression. Some causes include:  

• Relationship breakdown (such as bereavement, divorce, the departure of friends) 
• Important goals or ambitions that cannot be achieved 
• Losing your job, other meaning roles, or income 
• Serious illness or other threats to future plans 

Cancer and its treatment can disrupt daily activities, interfere with plans, relationships, challenge our control over our lives, and threaten our sense of self identity. All of these involve the loss of things in the past, present and future that are important to most people. 

Some people are more prone to depression. You may be more vulnerable if: 

• You have direct relatives (grandparents, parents and siblings) who had depression.
• You were a victim of abuse, or lost a parent during childhood.
• You have had previous attacks of depression. You have an illness, or take medication, which can cause depression as a side effect. 

Depression in cancer patients

Cancer patients are more likely to be depressed than healthy people, but no more likely than people with other serious illnesses.  In cancer, depression is most commonly associated with: 

• Feeling of lossing control over your health, your life or activities
• Changes in body appearance (loss of hair, skin or weight changes) or body function (fatigue, loss of a body part following surgery) 
• Anticipating future loss, such as retirement plans, children’s graduation or other achievements, financial issues, life expectancy
• Worries about impaired roles, family or work responsibilities
• Unresolved pain or other symptoms, like fatigue that prevent everyday activities
• Feeling hopeless or that life has no purpose because you have cancer
• Some anti-cancer medications which aggravate depression
• Poor sleeping which increases tiredness and depression

Patients with mild depression can be managed effectively with psychological support or cognitive behavioural therapy. However, for patients with moderate to severe depression, medications for depression (anti-depressants) are required. There is strong evidence that antidepressants are effective in treating depression in people with a life-threatening physical illness. 

There is no evidence of superior efficacy for a particular antidepressive agent. The doctor will assess your risk, previous drug history and current medications to select the type of anti-depressant. Drug compliance is important for treating depression so you can consider making a record of your medication habits. 

These are some common types of anti-depressants: 

Selective serotonin reuptake inhibitors (SSRI)

• SSRIs are better tolerated and are safer in overdose than other classes of antidepressants and therefore are often considered first line drug.  
• Example: Sertraline, Citalopram, fluoxetine, Paroxetine 
• Side effects include: 
  • nausea, vomiting, anorexia, shortness of breath, diarrhoea 
  • risk of gastrointestinal (GI) bleeding - avoid or use with caution if there is history of GI bleeding, patient over 80 years or is taking non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin 
  • insomnia, sweating, impaired sexual function 
  • vivid dreams, agitation, hyponatraemia 

Serotonin and Noradrenaline Reuptake Inhibitors

• Example: Desvenlafaxine, Venlafaxine 
• Similar to SSRIs 
• Side effects: may cause hypertension at high doses 

Mirtazapine

• Can stimulate appetite and help sleep 
• Well tolerated in older patients and patients with heart failure 

Tricyclic antidepressants (under specialist advice)

• Example: amitriptyline, clomipramine, dothiepin, Imipramine 
• Side effects include: 
  • Dizziness, headache, sweating, tremor, somnolence, palpitation, dry mouth, constipation, blurred vision, difficulty passing urine, orthostatic hypotension 
  • Other less-common adverse effects include seizure, liver dysfunction, ECG changes, abnormal blood count 
• Patients with or have had a history of suicidal behaviour should avoid taking tricyclic antidepressants 

To manage depression, patients may need to arrange their daily activity schedule appropriately, maintain social interactions and seek professional assistance when necessary. 

Based on individual conditions, patients can consider the following suggestions to deal with depression: 

1. Break the vicious cycle of depression 

When you feel depressed, you tend not to see people you usually hang out with or stop doing the things you used to enjoy. However, avoiding other people will only reduce the chances of creating meaningful or pleasant experiences. You will in turn focus more on your worries, causing the depressive mood to persist. The first step of change is to do something different. Try to set some small goals for yourself. Do not wait until you feel good enough to take action. Take action to make yourself feel better. 

2. Plan your daily schedule to keep yourself active 

Physical problems may hinder your everyday activities, but you can still choose to fulfil some simple goals, and gradually take part in some activities to restore the previous everyday life. 

• Do not wait until you are happy enough to take any action. Having depressive symptoms may mean that you would need to wait for a long time before you take the first action. Take the first step whenever possible 
• Try to find pleasure in simple everyday activities, such as calling friends for a chat, sitting in the garden, taking a hot bath or shower, eating your favourite food or watching your favourite TV show 
• Plan what to do every day. Set realistic goals that are not too difficult. For example, you may find it too difficult to concentrate on reading a book, but reading a magazine or watching a TV show may be more doable. It may be easier to walk in a quiet garden than in a busy shopping mall. 
• If the activity is too complicated to be done in one go, divide it into several parts, such as sitting down and doing some stretching exercises, walking around the home or going out for a walk. If your condition allows, you may take a walk in the park. If you do not have enough physical strength or confidence, you may invite some relatives or friends to keep you company. 
• Write down your plan and check the items you have completed. Stick to your plan as much as possible but allow enough room for flexibility. If you miss an item, proceed to the next one or reschedule it to another day. 
• Rate the sense of enjoyment and accomplishment each activity brings (0-10 points). For example, in terms of fun, 10 points means you really like the activity and 0 points means you do not like it at all. You can rate the level of fun and accomplishment of every activity on a scale of 0-10. There are tasks (such as clearing drawers or processing files) that may not be very enjoyable (2 points for fun) but give a high sense of accomplishment (10 points for achievement). By rating the activities, you can remind yourself of what to spend time on and observe what makes you happy or gives you a sense of achievement. In the future, you can try to spend more time on the high-scoring activities 

3. Try to arrange outdoor activities 

Outdoor activities help improve your physical and mental health. “Outdoor” includes all outdoor green spaces, such as country parks, gardens and parks in the city. Contact with nature can help you relax, reduce stress and improve your mood. 

4. Keep a diary

Keep a dairy of things you have achieved, things that make you happy and things to be grateful for. This would let yourself realise there is more around you to treasure and enjoy. You can also practise writing down your negative thoughts in your diary (for example: “My illness will not get better.”) and write another sentence that is closer to reality next to the previous sentence (for example: “Even with the illness, I can still live well.” Or “My physical discomfort can be relieved.”) This can help you adjust your emotions when negative thoughts pour in. 

5. Keep in touch with your family and friends 

Share your personal experience with people you trust, so that you know someone is willing to listen to your problems and care about your condition. You can also make use of different hotlines to talk about your problems and concerns in a confidential manner and reach out for help when necessary. 

6. Seek professional assistance 

When your depressive symptoms significantly affect your daily functioning, you may need to reach out to healthcare professionals for assistance. They will provide suitable treatments and recommendations based on your conditions to help you manage the symptoms more effectively. 

HKU Med: Jockey Club Institute of Cancer Care: Depression Management

Smart Patient Website, Hospital Authority, Depression