A Common and Expected Sad Mood
Sadness is a universal human emotion in response to various life events that interfere with our ability to experience pleasure, and it casts a negative cloud over our outlook. It is the rare person who has not experienced sadness at least once in his or her lifetime. Sadness has also been described as part of the common and complex set of emotions experienced when cancer is suspected or confirmed. Part of a usual and expected reaction, such a turbulent time can also involve fearing that one's life will be changed, doubting one's abilities to care for ourselves or our families, and doubting our abilities to work or go to school. You may also have fears about a loss of independence, being in pain, feeling helpless and worrying about the length or quality of life. Moving through a sense of shock and disbelief or anger most often leads to a mobilization of self, family and resources as diagnostic testing and various types of treatment are established, then into a period of survivorship.

Such a usual and expected reaction is as much a part of the experience as physical exams, blood tests and imaging tests, and it often lasts for a few weeks at a time, with a recrudescence at predictable points. Social support from our friends, families and spiritual framework combined with skilled care and emotional resiliency can buffer those feelings to sustain us through treatment and beyond.

Depression in Cancer: More Than Expected Sadness
A sizable minority estimated at about 20 percent, have more profound feelings of sadness. With an almost complete absence of enjoyment for anything, a sense of hopelessness can descend that far exceeds the likelihood of a good response to treatment and recovery. Often labeled as feelings of depression, they are commonly associated with changes in appetite, restorative sleep, motivation or concentration on tasks, even pleasurable ones. The term depression though, is also used in everyday language to describe feeling angry, let down or disrespected. That everyday context makes an episode of major depression more elusive and harder to grasp in the midst of cancer.

As we have learned more about depression in the general population, so have we learned about depression in cancer. A predisposition to depression tends to run in families, along with substance abuse and suicide. Certain types of cancers are more likely associated with a depression than others, particularly pancreatic, head and neck cancers or gastric (not colorectal) cancer. Circulating cytokines formed as cancer grows (cyto = cell; kine = protein) enter the brain and simulate the symptoms of depression. Many chemotherapy drugs cross into the brain with greater difficulty and can also be associated with mood changes. The sedating side effects of anti-nausea and pain medications seem to amplify or mimic the perception of depression.

There are a number of interventions that have proven effective when depression outside of the boundaries of the expected sadness appears with cancer. It is important to alert your treatment team about your feelings and reactions. Be candid if close blood relatives suffer with depression, alcohol or substance dependence, whether treated or not. Counseling is widely available in-person at your treatment center, in your community or electronically on the telephone or on-line. As with the other aspects of cancer treatment, look for help from specialists trained in the specifics of cancer. Judicious use of antidepressant medications coordinated with chemotherapy, radiation therapy or cancer surgery is tried and true as well as effective, especially when experienced providers are part of your care team.

Stigma Can Prevent Effective Intervention
A seemingly insurmountable barrier comes from the stigma of admitting such negative feelings to your primary cancer providers. It is essential to do so in that the referral to counseling or treatment with antidepressants can only begin with honest discussion. The recommendation for counseling or medication is far from a one size fits all approach, optimally tailored to the other components of your care. Family members and close friends often take it upon themselves to act as your agent if the foreboding of depression stands in the way of self-advocacy. Through a variety of clinical trials and expert reports, treatment of depression in cancer has been shown to be way more successful than not. There are fewer interactions and less complicated dosing schedules associated with medications introduced over the last twenty years.

Sustaining one's quality of life is a challenge during and after cancer treatment, and the burdens of untreated depression make them seem more onerous.