My breast cancer diagnosis was an extreme blow. One minute, I was a healthy and happy 47-year-old woman. The next, I had a tumor that could take me away from my school-aged children far too soon. My providers were amazing in how fast they moved. Within days I saw two surgeons, two reconstruction specialists, a DNA specialist, a nutritionist, a radiologist and multiple oncologists. We made a plan quickly and I was strong and positive enough to fight. Or so I thought.
No one prepared me for the emotional journey in which I was embarking. The stress of telling my children, my friends, my work. Losing my hair and eventually losing strength. Having a fear so strong it caused me to worry at every turn. There were a lot of ups and downs in the beginning, and monitoring my emotions was just as important as my body.
So, I know from experience that helping breast cancer patients deal with depression is key. Here, two mental health professionals who manage breast cancer patients provide some guidance for clinicians unfamiliar with this journey.
Determine If It Is Depression or Distress
Symptoms of clinical depression include sadness, tearfulness, anxiety, fatigue, difficulty concentrating, insomnia or hypersomnia (sleeping more than usual), weight change, thoughts of death, suicidal thoughts, suicide attempts, feeling guilty, helpless and worthless, and loss of interest in usual activities.
“These symptoms are very common during the cancer treatment trajectory, as well as when treatment ends,” says Pamela Ginsberg, PhD, Staff Psychologist at Doylestown Health and Board of Directors member for the Cancer Support Community of Greater Philadelphia.
But diagnosis is difficult because many of these responses characterize a normal response to a cancer diagnosis. “There is a difference between depression and distress,” adds Greg Garber, MSW, LCSW, Director Patient Support Services, Neu Center for Supportive Medicine and Cancer Survivorship at Philadelphia’s Sidney Kimmel Cancer Center. “Depression is a defined syndrome. Distress is experiencing highs and lows, happiness and sadness, and are often the result of the anxiety that comes when a patient is diagnosed with breast cancer.”
Anxiety is also common after a breast cancer diagnosis. According to Garber, it goes away in about half of patients after they develop a better sense of what to expect from treatment.
Watch for Risk Factors
Clinical depression occurs in about 20 to 25 percent of cancer patients, significantly higher than the general population’s rate of between 7 and 10 percent, says Ginsberg. If a patient has a personal history of a major depressive disorder, a family history of depression, uncontrolled pain, has advanced cancer and/or a history of substance abuse or addiction, he or she is at greater risk of depression, even after treatment is over.
Anxiety can also last well beyond treatment, often due to a general anxiety disorder. In these cases, it’s best to refer the patient to a psychologist who treats chronic anxiety.
Be Cautious With Prescriptions
Prescribers often turn to antidepressants or anti-anxiety medication for clinical depression and distress.
But, Garber clarifies, “not everyone who cries in your office needs medicine. Sometimes PCPs are too quick to prescribe medications … Although anti-anxiety medications such as Xanax and Valium can be a good short-term solution to help a patient sleep, get through their initial anxiety and even control nausea during chemotherapy, these are short-term solutions.”
Ginsberg also cautions that some antidepressants interfere with hormonal treatments that breast cancer patients often receive.
“Some antidepressants are not well-tolerated, and many patients express concern about additional medications,” she says. “In mild to moderate depression, psychotherapy alone may suffice, but in more severe depression, antidepressants are often needed.”
Much of what breast cancer patients experience is fear of the unknown, so “give your patients a little extra time to answer questions and concerns and help them come to terms with what they are going through,” says Garber.
You should also lean on your patient’s oncologist if you need help providing emotional support, but base your decision to do so on your relationship with the patient.
“Oncologists pay close attention to the signs of distress and depression,” Garber explains.”If you only see a patient for managed care once or twice a year, refer them to their oncologist. If you have a tremendous relationship with your patient, help provide them with the comfort they need during this time.”
Enlist Help from Mental Health Experts
“If you recognize, diagnose or suspect depression, a referral to a licensed mental health professional is warranted,” Ginsberg says. “Referring a patient to someone who has a training and experience treating cancer patients is particularly helpful. Support groups are also extremely useful, though individual treatment is highly recommended when clinical depression is present. The standard of care for treatment of depression is psychotherapy combined with medication.”
Collaborate with the Patient’s Entire Care Team
Breast cancer patients see several providers at once, so working closely with them to understand the intricacies of the treatment plan is crucial.
“In a perfect world, once a cancer survivor finishes with oncology, they can be placed back in the care of their PCP with all of the details of survivorship guidelines, such as when a patient is put on hormone-blocking drugs, and then their PCP will be more alert for bone density concerns,” says Garber.
“There is no doubt that treatment is usually more cohesive when all of the treating health professionals are in communication with one another,” adds Ginsberg. “When there are mental health concerns on the part of the PCP, then it is wise to talk with the treating psychologist about how they can work together to support the patient’s needs.”