Overcoming Depression

If you are dealing with cancer, there are many reasons that you may have felt depressed from time to time, or at least felt 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-style and threatening the roles, purposes, and goals that give meaning and satisfaction to your life. Cancer therapies may have debilitating side-effects and, in some cases, cause irreparable damage to one's body. Cancer not only affects you, but also your loved ones....and much of your emotion is felt for them.

It is not surprising that a significant percentage of cancer patients have episodes of depression. When this happens, your entire experience with cancer is more difficult; your resilience is weakened, and overall adjustment can be hampered. Depression can also 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 therefore a serious threat those who are dealing with cancer. Fortunately, you can protect yourself from depression, and there are effective remedies for it. This chapter will explain depression, how cancer can cause it, and what you can do about it.

Most of us have been depressed at some time and know what it feels like. Three complaints are especially common: 1) the loss of interest in things you used to enjoy (even a simple pleasure, such as listening to one's favorite music, could lose its appeal to you); 2) feeling sad, blue, or down in the dumps, and being tearful or crying easily; and 3) 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 also feel pessimistic and hopeless, and begin to welcome death as a relief and to think of suicide. Depression can cause you to feel worthless and guilty,

Some of the mental problems that accompany depression include difficulty concentrating, remembering things, or making decisions. Some of the physical complaints include loss of appetite, sleep disturbances, headaches, digestive problems, and loss of libido.

Depression can have psychological and/or biochemical causes. The psychological causes involve experiences and events that have a depressing impact; the biochemical causes involve imbalances in the neurochemistry of the brain. Sometimes the psychological causes lead to depression because of these biochemical changes.

The life experiences that cause depression do so because they carry certain meanings to the person involved. For example, if you were abused as a child, you might conclude that you were undeserving of love or a happy life. Thoughts of being unworthy, whether conscious or unconscious, then cause depression. Other thoughts that commonly underlie depression involve the sense of helplessness, hopelessness, and being a victim. These thoughts and feelings have their origin in traumatic events in the person's life (although often the person does 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. However, sometimes this imbalance does not seem to be related to psychological factors. The 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. Consequently, sometimes when you are depressed you can say what you are depressed about (i.e., the depressing situation or experiences) or be able to identify depressing thoughts (e.g., that nothing will make a difference); but in many case, you may not be aware of why you are depressed. This is because the psychological factors are unconscious and/or because the depression is caused by changes in the neuro-chemistry of the brain

As I will discuss later, the combined psychological and bio-chemical components of depression often require a treatment plan that includes psychological help and medication.

I mentioned earlier that cancer patients often have episodes of depression. One reason for this, of course, is that 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 certain psychological and/or biological reasons for it. As I hope to show, these causes are quite understandable, and also treatable. They have nothing to do with a weakness in character in those who become depressed.

First, let's discuss how the experience of cancer can cause depression (that is, the psychological cause for the depression....as opposed to the biochemical aspects, which I will get to later). In general, cancer can cause depression because of the various meanings of the illness that stem from the circumstances or psycho-logical background in which it occurred. Let me explain what I mean by this

Cancer happens to you as a person, not just to your body. You therefore experience it as part of your personal life, as opposed to being an isolated event that happened in a vacuum. Personal issues, themes, and feelings that are imbedded in your personal history are brought to the cancer experience and give that experience a certain meaning and feeling tone. The clearest example of this is seen in the different feelings about cancer that stem from the patient's age. In general, patients in their thirties bring to their cancer experience a feeling of incompletion 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 future holds. Patients in their eighties, on the other hand, generally bring some sense of life completion to their cancer experience, 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 have enjoyed.

Some other examples will illustrate how the context in which you experience cancer can contribute to depression. The feeling of sadness (for yourself and loved ones) evoked by a cancer diagnosis is not itself depression, but it can be magnified by other sorrows in your life such that it becomes depression. In this case, a sorrowful life history, prior to cancer, is the context in which the cancer is experienced. The cancer, for example, can represent a kind of "crowning blow" to a long history of abuse, misfortune, or frustration. It can therefore 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 the resulting "emotional baggage" that the person carried into the cancer experience.

Another example: prior to being diagnosed with cancer, suppose you had recently achieved an important life goal or were on the verge of doing so. This goal might concern your work life, love life, or children. 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 is stacked against you, or that you were having to pay a price for your ambition. These are meanings that cancer could hold for you -- meanings that grow out of 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....and 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 sometimes these feelings are ones of depression. Your feelings about yourself are, to varying degrees, dependent upon your bodily appearance and your physical abilities. This is true of all of us. 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.

In our culture, we often assume that what happens to a person is somehow linked to what that person deserves. Unfortunately, this assumption, which is often very subtle, can give rise to certain meanings or implications of cancer. When things are going well for us -- in our personal lives, in our work, and in our good health -- we tend to assume that we are doing something right, living on the right track, and must be deserving of our good fortune. The flipside of this assumption is that misfortune takes on a certain meaning -- i.e., that we were not so deserving of our good fortune after all, perhaps due to some flaw in our character, lack of virtue, having the wrong priorities, or living under too much stress. When people suffer the misfortune of a cancer diagnosis, therefore, it is not uncommon for them 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 i that they were enjoying more happiness than most people, and that cancer was a way of balancing things out. Again, these ideas -- that cancer is not just a biological malfunction, but that it somehow implicates a person and a person's life -- can cause depression

The nature of cancer also lends itself to the notion that it implies something about the person who has it. These cells -- which have spun out of control and which, if left to their own devises, are ultimately self-destructive -- are part of the person's body, originating from within, and it may seem that they therefore manifest some underlying personal pathology or dysfunction. One woman said of her cancer: "It's all of my repressed resentment and bitterness coming out." Another 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." It is depressing, of course, to feel that your cancer is a manifestation of some personal problem, whatever it may be.

As I mentioned, there are also biological causes of depression in cancer patients. The emotional impact of cancer can bring about biochemical changes in the brain, and these changes can also be caused (quite independently of any psychological issues) by certain chemotherapy drugs , hormonal treatments, anti-inflammatory drugs, pain medication, and radiation therapy. Later, I will discuss the role of anti-depressant medication, which is especially important given the biochemical component of depression

If you are depressed, it does not mean that you are not coping or adjusting as you should. It is often 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. Your depression may also be a side-effect of medical interventions for your cancer. But depression is dangerous, especially to your quality of life and will to live, and there are steps you can take to alleviate it

Protecting Yourself. There are four important ways of protecting yourself from depression when you are dealing with cancer.

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. You should also discuss these problems and emotions with a relative or close friend. As I mentioned above, depression often results from the suppression of emotion, such that these emotions do not have the outlet or discharge they need.

For example, when depression persists long after the loss of a loved one, it is often because the person's grief had not been adequately expressed. One theory is that non-expressed emotion builds up internally and causes 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 not uncommon if you do not know what you are depressed about. You might feel that you have no good reason for being depressed, especially because others have had 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 as to what these reasons are. Think about the many ways that cancer can cause depression, as discussed above, and 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. Give yourself permission 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, that may apply to you, is that you do not want to bother others with your feelings and needs. When you were young, your parents may have conveyed that children were to be seen but not heard; or you may have been especially sensitive to the problems that already existed in your family, and did not want to make matters worse by voicing your own difficulties. You may have inferred from these experiences that your need for comfort or support, when you were upset about something, would be an unwelcome burden on others. Such a belief could prevent you, even now, from expressing your feelings.

Another underlying belief, that prevents some people from confiding in others, is that they cannot or will not be comforted by doing so. Thus, it seems like a set-up for more hurt to even hope for emotional comfort from another person. Perhaps you did 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, as having developed from your earlier experience, it is important to recognize that they are not universally valid now -- that is, 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.

One 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, therefore has no emotional outlet or personal support, which then deepens the depression. 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, and lack of meaning, especially because of the painful cry of "Why me?" when 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. You might refer to ... how religion and spirituality can help when dealing with cancer.

Often the best help to obtain, when you are depressed, is from a mental health professional. 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 for you 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 some theories, these thoughts actually are the depression. In general, your therapy will consist of a process for 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.

In many cases, anti-depressant medication is also warranted, especially in combination with psychotherapy. Although depression usually has a psychological origin (in terms of what the person is depressed about), it is also associated with biochemical changes in the brain. The best known of these concern seratonin, one of the main neurotransmitters. When a neural impulse reaches the end of a nerve cell in the brain, it releases seratonin in the junction 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 re-absorbs the seratonin too quickly, such that an insufficient amount is left in the junction to enable the effective transmission of the impulse. 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 seratonin levels are too low. Some anti-depressants, which are called selective seratonin re-uptake inhibitors (SSRI's), block the re-absorption of seratonin so that there is more left in the junction between cells to aid neuro-transmission. When this occurs, the symptoms of depression are often relieved.

There are other types of anti-depressant medication besides the SSRI's., and each of these work a little differently. Your physician or psychiatrist will seek to 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 least side effects. It is important to realize that it may take weeks for an anti-depressant to take its full effect

The symptomatic relief provided by an anti-depressant 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 anti-depressant medication.

To summarize: depression is a serious threat to your ability to cope with cancer, and to your will to live. It 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. The depression of cancer can make you feel that you can't go on and that it's not worth the effort. But there are reasons for depression that have nothing to do with weakness of character, and there are effective ways of combating and overcoming it.

Reprinted with permission
Chapter on Depression for Comprehensive Guide
by Andrew Kneier, Ph.D., November 3, 1996

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