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Treatment
Treatment with Drugs
Treatment with Psychotherapy
Treatment with Drugs
Major depression may be treated with a combination of counseling and medications (drugs), such as antidepressants. A primary care doctor may prescribe
medications for depression and refer the patient to a psychiatrist or psychologist for the following reasons:
- A physician or oncologist is not
comfortable treating the depression (for example, the patient has suicidal thoughts).
- The symptoms of depression do not improve after 2 to 4 weeks of
treatment.
- The symptoms are getting worse.
- The side effects of the medication
keep the patient from taking the dosage needed to control the depression.
- The symptoms are interfering with the patient's ability to continue
medical treatment.
Antidepressants are usually effective
in the treatment of depression and its symptoms. Unfortunately,
antidepressants are not prescribed often for patients with cancer. About 25% of all patients are depressed, but only about 16% receive medication for the
depression. The choice of antidepressant depends on the patient's symptoms,
potential side effects of the antidepressant, and the person's individual
medical problems and previous response to antidepressant drugs.
The Food and Drug Administration (FDA) has issued a warning that patients who are taking antidepressants, such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro), bupropion (Wellbutrin), venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron), should be closely monitored for signs of worsening depression and suicidal thoughts. A Patient Medication Guide (MedGuide) should also be given to patients receiving antidepressants to warn them of the risk and suggest precautions that can be taken.
The FDA has also directed manufacturers of all antidepressant drugs to change the labeling for their products to include a boxed warning and more detailed warning statements about increased risk of suicidal thinking and behavior in children and adolescents being treated with antidepressants. Some studies show that the benefits of proper antidepressant use in children and adolescents, including careful monitoring for suicidal behavior, may outweigh the risks. However, for children younger than 12 years with major depression, only fluoxetine (Prozac) showed benefit compared to a placebo.
Patients with cancer may be treated with a number of drugs throughout their care. Some drugs do not mix safely with certain other drugs, foods, herbals, and nutritional supplements. Certain combinations may reduce or change how drugs work or cause life-threatening side effects. It is important that the patient's healthcare providers be told about all the drugs, herbals, and nutritional supplements the patient is taking, including drugs taken in patches on the skin. This can help prevent unwanted reactions.
St. John's wort (Hypericum perforatum) has been used as an over-the-counter supplement for mood enhancement. In the United States, dietary supplements are
regulated as foods, not as drugs. The FDA does not require that supplements be approved before being put on the market. Because
there are no standards for product manufacturing consistency, dose, or purity,
the safety of St. John's wort is not known. The FDA has issued a warning that
a significant drug interaction occurs between St. John's wort and indinavir (a drug used to treat HIV infection). When St. John's wort and indinavir are
taken together, indinavir is less effective. Patients with symptoms of
depression should be evaluated by a health professional and not self-treat with
St. John's wort. St. John's wort is not recommended for major depression in
patients who have cancer.
Most antidepressants take 3 to 6 weeks to begin working. The side effects must
be considered when deciding which antidepressant to use. For example, a
medication that causes sleepiness may be helpful in an anxious patient who is
having problems sleeping, since the drug is both calming and sedating.
Patients who cannot swallow pills may be able to take the medication as a
liquid or as an injection. If the antidepressant helps the symptoms, treatment
should continue for at least 6 months. Electroconvulsive therapy (ECT) is a
useful and safe therapy when other treatments have been unsuccessful in
relieving major depression.
Treatment with Psychotherapy
Several psychiatric therapies have been found to be helpful in the
treatment of depression related to cancer. Most therapy programs for depression are given in 4 to 30 hours and are offered in both individual and group settings. They may include sessions about cancer education or relaxation skills. These therapies are often used in
combination and include crisis intervention, psychotherapy, and
thought/behavior techniques. Patients explore methods of lowering distress, improving coping and
problem-solving skills; enlisting support; reshaping negative and
self-defeating thoughts; and developing a close personal bond with an
understanding health care provider. Talking with a clergy member may also be
helpful for some people.
Specific goals of these therapies include the following:
- Assist people diagnosed with cancer and their families by answering
questions about the illness and its treatment, explaining information,
correcting misunderstandings, giving reassurance about the situation,
and exploring with the patient how the diagnosis relates to previous
experiences with cancer.
- Assist with problem solving, improve the patient's coping skills, and
help the patient and family to develop additional coping skills.
Explore other areas of stress, such as family role and lifestyle
changes, and encourage family members to support and share concern
with each other.
- Ensure that the patient and family understand that support will continue when the focus of treatment changes from trying to cure the cancer to
relieving symptoms. The health care team will treat symptoms to help the patient control pain and remain comfortable, and will help the patient and his or her family members maintain dignity.
Cancer support groups may also be helpful in treating depression in
patients with cancer, especially adolescents. Support groups have been shown to improve
mood, encourage the development of coping skills, improve quality of life, and
improve immune response. Support groups can be found through the wellness
community, the American Cancer Society, and many community resources, including
the social work departments in medical centers and hospitals.
Recent studies of psychotherapy in patients with cancer, including training in problem solving, have shown that it helps decrease feelings of depression.
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