Treatment

Treatment with Drugs
Treatment with Psychotherapy
Current Clinical Trials

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 to treat depression. Many studies have been done to compare St. John's wort with antidepressants, placebo (inactive) drugs, or both, and have shown mixed results. An overview of 37 randomized, controlled clinical trials in patients with depression showed that St. John's wort does not have a strong effect on major depression, but may have a slight effect on mild depression.

Side effects reported in studies of St. John's wort are minor. An overview of clinical trials comparing St. John's wort with antidepressants found that fewer patients dropped out of studies due to side effects of St. John's wort than due to side effects of antidepressants.

Patients with symptoms of depression should not self-treat with St. John's wort. This supplement may change the way certain drugs act in the body. Patients should see a doctor to review their current medications before taking St. John's wort to avoid possible drug interactions.

Cautions about using St. John's wort for depression include the following:

• St. John's wort is regulated by the FDA as an herbal supplement/food, not as a drug. The amount of active ingredients in St. John's wort preparations is not standardized and may differ by brand.

• St. John's wort can make certain drugs less effective, including:
  • Irinotecan and possibly docetaxel for the treatment of cancer.
  • Cyclosporin A and tacrolimus to lower the risk of organ and bone marrow transplant rejection.
  • Indinavir for the treatment of HIV.

St. John's wort is not recommended as a treatment for depression due to its lack of strong effect, lack of standardization, and possible interaction with other medications.

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.

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.

Check NCI’s list of cancer clinical trials for U.S. supportive and palliative care trials about depression that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.