The symptoms of major depression include the following:

• Having a depressed mood for most of the day and on most days.



• Loss of pleasure and interest in most activities.



• Changes in eating and sleeping habits.



• Nervousness or sluggishness.



• Tiredness.



• Feelings of worthlessness or inappropriate guilt.



• Poor concentration.



• Constant thoughts of death or suicide.

To make a diagnosis of depression, these symptoms should be present on most days for at least 2 weeks. The diagnosis of depression can be difficult to make in people with cancer due to the difficulty of separating the symptoms of depression from the side effects of medications or the symptoms of cancer. This is especially true in patients undergoing active cancer treatment or those with advanced disease. Symptoms of guilt, worthlessness, hopelessness, thoughts of suicide, and loss of pleasure are the most useful in diagnosing depression in people who have cancer.

Some people with cancer may have a higher risk for developing depression. The cause of depression is not known, but the risk factors for developing depression are known. Risk factors may be cancer-related and noncancer-related.

• Cancer-Related Risk Factors:
  • Depression at the time of cancer diagnosis.
  • Poorly controlled pain.
  • An advanced stage of cancer.
  • Increased physical impairment or pain.
  • Pancreatic cancer.
  • Being unmarried and having head and neck cancer.
  • Treatment with some anticancer drugs.



• Noncancer-Related Risk Factors:
  • History of depression.
  • Lack of family support.
  • Other life events that cause stress.
  • Family history of depression or suicide.
  • Previous suicide attempts.
  • History of alcoholism or drug abuse.
  • Having many illnesses at the same time that produce symptoms of depression (such as stroke or heart attack).

The evaluation of depression in people with cancer should include a careful evaluation of the person's thoughts about the illness; medical history; personal or family history of depression or suicide; current mental status; physical status; side effects of treatment and the disease; other stresses in the person's life; and support available to the patient. Thinking of suicide, when it occurs, is frightening for the individual, for the health care worker, and for the family. Suicidal statements may range from an offhand comment resulting from frustration or disgust with a treatment course, such as "If I have to have one more bone marrow aspiration this year, I'll jump out the window," to a statement indicating deep despair and an emergency situation, such as, "I can't stand what this disease is doing to all of us, and I am going to kill myself." Exploring the seriousness of these thoughts is important. If the thoughts of suicide seem to be serious, then the patient should be referred to a psychiatrist or psychologist, and the safety of the patient should be secured.

The most common type of depression in people with cancer is called reactive depression. This shows up as feeling moody and being unable to perform usual activities. The symptoms last longer and are more pronounced than a normal and expected reaction but do not meet the criteria for major depression. When these symptoms greatly interfere with a person's daily activities, such as work, school, shopping, or caring for a household, they should be treated in the same way that major depression is treated (such as crisis intervention, counseling, and medication, especially with drugs that can quickly relieve distressing symptoms). Basing the diagnosis on just these symptoms can be a problem in a person with advanced cancer since the illness may be causing decreased functioning. It is important to identify the difference between fatigue and depression since they can be assessed and treated separately. In more advanced illness, focusing on despair, guilty thoughts, and a total lack of enjoyment of life is helpful in diagnosing depression. (Refer to the PDQ summary on Normal Adjustment and the Adjustment Disorders ¹ for further information.)

Medical factors may also cause symptoms of depression in patients with cancer. Medication usually helps this type of depression more effectively than counseling, especially if the medical factors cannot be changed (for example, dosages of the medications that are causing the depression cannot be changed or stopped). Some medical causes of depression in patients with cancer include uncontrolled pain; abnormal levels of calcium, sodium, or potassium in the blood; anemia; vitamin B ₁₂ or folate deficiency; fever; and abnormal levels of thyroid hormone or steroids in the blood.

Glossary Terms

Not normal. An abnormal lesion or growth may be cancerous, premalignant (likely to become cancer), or benign (not cancerous).

Cancer that has spread to other places in the body and usually cannot be cured or controlled with treatment.

A disease in which a person craves alcohol, is unable to limit his or her drinking, needs to drink greater amounts to get the same effect, and has withdrawal symptoms after stopping alcohol use. Alcoholism affects physical and mental health, and causes problems with family, friends, and work. Also called alcohol dependence.

A condition in which the number of red blood cells is below normal.

A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away wastes.

The removal of a small sample of bone marrow (usually from the hip) through a needle for examination under a microscope.

A mineral found in teeth, bones, and other body tissues.

A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

The process by which a professional counselor helps a person cope with mental or emotional distress, and understand and solve personal problems.

Immediate, short-term counseling (talking with a professional counselor) to stop a critical emotional incident (e.g., attempted suicide or drug overdose) from getting worse. Crisis intervention is not meant to solve the problem that led up to the crisis.

In medicine, a shortage of a substance (such as a vitamin or mineral) needed by the body.

A mental condition marked by ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life. Other symptoms of depression include feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide. Depression can affect anyone, and can be successfully treated. Depression affects 15-25% of cancer patients.

The process of identifying a disease, such as cancer, from its signs and symptoms.

Extreme mental or physical pain or suffering.

The amount of medicine taken, or radiation given, at one time.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

The use of illegal drugs or the use of prescription or over-the-counter drugs for purposes other than those for which they are meant to be used, or in large amounts. Drug abuse may lead to social, physical, emotional, and job-related problems.

A record of a person's current and past illnesses, and those of his or her parents, brothers, sisters, children, and other family members. A family history shows the pattern of certain diseases in a family, and helps to determine risk factors for those and other diseases.

A condition marked by extreme tiredness and inability to function due lack of energy. Fatigue may be acute or chronic.

An increase in body temperature above normal (98.6 degrees F), usually caused by disease.

A nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy. Folate helps to make red blood cells. It is found in whole-grain breads and cereals, liver, green vegetables, orange juice, lentils, beans, and yeast. Folate is water-soluble (can dissolve in water) and must be taken in every day. Not enough folate can cause anemia (a condition in which the number of red blood cells is below normal), diseases of the heart and blood vessels, and defects in the brain and spinal cord in a fetus. Folate is being studied with vitamin B12 in the prevention and treatment of cancer. Also called folic acid.

Cancer that arises in the head or neck region (in the nasal cavity, sinuses, lips, mouth, salivary glands, throat, or larynx [voice box]).

A loss of part or all of a physical or mental ability, such as the ability to see, walk, or learn.

A legal drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition.

A disease in which malignant (cancer) cells are found in the tissues of the pancreas. Also called exocrine cancer.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

A metallic element that is important in body functions such as regulation of blood pressure and of water content in cells, transmission of nerve impulses, digestion, muscle contraction, and heartbeat.

A medical doctor who specializes in the prevention, diagnosis, and treatment of mental, emotional, and behavioral disorders.

A specialist who can talk with patients and their families about emotional and personal matters, and can help them make decisions.

Something that may increase the chance of developing a disease. Some examples of risk factors for cancer include age, a family history of certain cancers, use of tobacco products, certain eating habits, obesity, lack of exercise, exposure to radiation or other cancer-causing agents, and certain genetic changes.

A problem that occurs when treatment affects healthy tissues or organs. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.

A mineral needed by the body to keep body fluids in balance. Sodium is found in table salt and in many processed foods. Too much sodium can cause the body to retain water.

The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.

A type of drug used to relieve swelling and inflammation. Some steroid drugs may also have antitumor effects.

The response of the body to physical, mental, or emotional pressure. This may make a person feel frustrated, angry, or anxious, and may cause unhealthy chemical changes in the body. Untreated, long-term stress may lead to many types of mental and physical health problems.

In medicine, a loss of blood flow to part of the brain, which damages brain tissue. Strokes are caused by blood clots and broken blood vessels in the brain. Symptoms include dizziness, numbness, weakness on one side of the body, and problems with talking, writing, or understanding language. The risk of stroke is increased by high blood pressure, older age, smoking, diabetes, high cholesterol, heart disease, atherosclerosis (a build-up of fatty material and plaque inside the coronary arteries), and a family history of stroke.

The act of taking one's own life on purpose.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.

A hormone that affects heart rate, blood pressure, body temperature, and weight. Thyroid hormone is made by the thyroid gland and can also be made in the laboratory.

A nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy. Vitamin B12 helps make red blood cells, DNA, RNA, energy, and tissues, and keeps nerve cells healthy. It is found in liver, meat, eggs, poultry, shellfish, milk, and milk products. Vitamin B12 is water-soluble (can dissolve in water) and must be taken in every day. Not enough vitamin B12 can cause certain types of anemia (a condition in which the number of red blood cells is below normal) and neurologic disorders. It is being studied with folate in the prevention and treatment of some types of cancer. Also called cobalamin and cyanocobalamin.