CMLNews: Thank you Mark for taking
some time to talk to us today about depression
and cancer, specifically CML. First,
can you define depression for us?
Dr. Heiland: Depression is actually not easy to define. We
think of it as a cluster of symptoms, a cluster of affective,
physiological, and behavioral symptoms. So let me explain
each of the symptoms. First of all, one experiences a
depressed mood, feeling sad or blue along perhaps with a
decrease in motivation or interest in things that the person is
normally interested in.
CML News: So if you normally sit and play the piano and
all of a sudden you aren’t doing it, that could be a sign of
depression?
Dr. Heiland: Even more profoundly, a loss of the sense
of pleasure. Things that normally provide comfort and
pleasure no longer provide it. It’s more than a lack of
interest in a hobby.
CML News: If your favorite food doesn’t interest you?
Dr. Heiland: It could be eating in general, not just your
favorite food. It could also be an increase in eating. In
other words, a change in eating habits that cause a
significant change in weight can be a symptom of
depression. Another symptom can be sleep disturbance, trouble falling
asleep, waking in the middle of the night or early morning
and not being able to fall asleep again.
CML News: Could that include more napping during the
day?
Dr. Heiland: Yes, that could follow from the sleep
disturbances at night. Sometimes people sleep a lot more
than usual, too, and have difficulty getting out of bed.
Sometimes people experience restlessness in their bodies
and there is behavioral activity such as wringing of hands or
difficulty sitting still to the point that someone else would
notice the change in behavior. Conversely, someone could become very lethargic so that
normal day-to-day activities take more effort and speech is
slowed. Affective symptoms include feelings of worthlessness, that
is, a feeling of low self-esteem. Another affective symptom is guilt about things the person
has no control over. We’re not talking about guilt over
something that you did and feel regret for; it is guilt over
things you have no control over. People with depression may experience changes in their
cognitive abilities: decrease in memory, difficulty
concentrating, poor attention span and decreased ability to
make decisions. The final symptom we think about is suicidal thoughts and
thoughts about death and dying. Now with these cluster of symptoms, for cancer patients,
there is difficulty to diagnose because some of the symptoms
can be a result of the disease or treatment of the disease. Right?
CML News: Right!
Dr. Heiland: Thoughts of death and dying I think are quite
normal for cancer patients. It is difficult to tease out
whether these thoughts are the result of depression or lifethreatening
cancer. It is normal for cancer patients to think about
death and dying as they confront their own mortality.
CML News: Or thoughts of a painful death that cancer can
bring?
Dr. Heiland: Right. That potential threat is very real for
cancer patients. So it is normal to think about them. What is
problematic is constant dwelling on thoughts about death, or
thinking about ending one’s life. If one has persistent suicidal
thoughts or intent to harm themselves, I recommend
immediate psychiatric care. That should be thought of as a
medical emergency.
CML News: You’ve defined or described a group of
symptoms of depression. Obviously there are causes to some
of these symptoms. For example, some medications can cause
sleep disturbances and it isn’t a result of depression. The
same with fatigue. How do you differentiate between the
symptoms caused by depression and those caused by
medications?
Dr. Heiland: That is a difficult question to answer. I
interview cancer patients extensively and attempt to tease out
that information. Usually the patient knows if a particular
symptom is caused by the medication, cancer or treatment.
Sometimes though, people are not sure, so it is important to
get as much information as possible. One important piece of
information is the timing of the symptoms. Do they occur
consistently during a part of the chemotherapy cycle or since
cancer diagnosis? So, we have a discussion about each
symptom and whether or not they are thought to be caused by
the cancer, cancer treatment, or by depression. Sometimes
people are not aware that a depressive symptom can be
caused by the treatment, so we discuss that possibility too.
I’m sorry there isn’t a definitive answer to your question.
It’s part of the challenge in diagnosing depression.
CML News: It’s a matter of determining how much is
attributable to the treatment or disease and how much is
part of depression?
Dr. Heiland: Right. And I think that if there is a question,
I’ll err on the side of caution and attribute it to depression
so that depression is treated appropriately.
From the list of symptoms that I gave earlier, we say that
there is clinical depression if five or more symptoms are
apparent for two weeks, nearly every day and most of the
day. Of course, there are degrees of depression.
With the first two symptoms I described, depressed mood
and loss of interest, one of those along with four other
symptoms indicates clinical depression. That is the diagnostic
criteria we go by. Again, the symptoms occur most
every day, most of the day, for two or more weeks.
CML News: One of the things that I wanted to ask you
was telling the difference between stress, sadness, anger
and other possible symptoms of depression that occur with
a leukemia diagnosis verses depression. You are saying that
the symptoms would occur daily for two weeks to lead you
to believe the patient has depression? When a person
comes to you, and it’s not a true depression, they are still
seeking help. What can we as patients do?
Dr. Heiland: There may be two separate issues here. One is a
depression caused by medical condition and one is depression
as we attempt to adjust to cancer.
Let me talk about the latter. Of course with the diagnosis of
cancer, people experience a lot of stress, sadness, and worry,
and these symptoms can be a linked to the diagnosis of
cancer. However, people can have anxiety about a cancer
diagnosis and still not have an anxiety disorder. The same is
true of depression. In this case, we might think of someone
having difficulty adjusting to the diagnosis. If there is
impairment in an important part of life, for example, work,
school, or social functioning, then we consider a diagnosis of
adjustment disorder.
With a normal response to a cancer diagnosis, I would expect
all the same things to happen, depressed mood, anxiety, feeling
overwhelmed, but there wouldn’t be the impairment in
social functioning. Everyone goes through a crisis time with
the diagnosis of cancer. I haven’t met anyone who hasn’t. But
many people, through their own internal resources, amazingly
adjust to cancer and these symptoms subside. Many people
initially lose control of their emotions and develop tearfulness
or episodes of anger, whatever it is, but these symptoms more
often than not subside over time.
With the depressive symptoms caused by a medical
condition, it is more challenging in a sense. Many people
confuse depression with fatigue or other physiological
symptoms of treatment. It looks like depression, and may
be experienced much like depression, but it isn’t the same
thing.
There are physiological reasons for depression caused by a
medical condition. Some cancers such as pancreatic cancer
and frontal lobe tumors are known to cause depression.
Some people experience depression during their chemo
treatments or between treatments, but they are not
depressed in the clinical sense.
CML News: With CML patients on continual chemotherapy
whether it be Gleevec, Sprycel, or an investigational
drug, we take our chemo daily. Other than bone marrow
transplant, there is currently no cure for CML so we take
the chemo the rest of our lives. Some of our group members
have talked about depression. We are reminded every
day when we take those pills that we have leukemia and are
fighting a life-threatening disease. Could this constant
reminder of leukemia contribute to a spiral of depression?
Dr. Heiland: Yes, it could contribute. We haven’t really
talked about the psychological causes of depression yet.
Let’s talk about that now and then get back to your question.
There are various theories of depression out there. Let’s
touch on them. First of all, there are medical reasons for
clinical depression; imbalances in certain neurotransmitters
in the brain like serotonin, dopamine, and norepinephrine
may cause depression. So, trying to restore those transmitters
to normal functioning is the goal of medical treatment for
depression.
An episode of intense stress can trigger a major depressive
episode. So even if someone doesn’t have a history of
depression, a person may become depressed following a
cancer diagnosis. Studies show that about 70% of initial
depressive episodes are attributable to a major stressor in
someone’s life.
CML News: A leukemia diagnosis is certainly a major
stressor.
Dr. Heiland: Absolutely, absolutely!
There are theories out there about early life experiences or
negative beliefs about oneself that develop over time, any of
which might cause depression. One doesn’t know how to get what
is needed to enhance the self. Cognitive theory is probably
the most accepted psychological understanding of depression
right now and enjoys a lot of respect and research support in
my field. One of the main ideas is that that how we think
about our mental and emotional experience can lead to depression.
It isn’t so much that we have negative thoughts, as
we all do, but how we respond to those negative thoughts. An
example might be the thought that chemotherapy is never
going to end and that feeling good is never going to happen.
These thoughts are maladaptive in that they are global and
imply that life will always be difficult. If these thoughts go
unchecked and are expanded, they certainly can lead to
depressed mood. So being aware of our thoughts and our
thought processes, and how we interpret our mental and
emotional experience is an important and therapeutic
activity. There is also the understanding that suggests interpersonal
stressors can cause depression. I recently read a
paper that attempted to integrate all of these theories of
depression, and the author came up with four potential
dimensions of depression and implications for treatment.
First, negative self-evaluations or negative self-view may
contribute to depressed mood. Secondly, lack of selfreinforcement
or the inability to engage in activities that are validating
may play a role in depressive symptoms. Difficulty to access support,
lack of support, social isolation and so on may also contribute. And
finally, a lack of meaning and purpose
may trigger depressed mood.
So, this integrative approach is interesting
to me because it really is a
summary of all the theories that are
out there. It also suggests some areas
that we might address in treatment.
Back to the statement you said about
taking the pills every day and being
reminded of CML each time you take
your pills. Yes, you are reminded
daily. I do not want to minimize your
experience, but it is the thoughts that
follow that you can work with.
CML News: So if I say to myself,
“Oh my gosh, I have this CML, and
have to take this drug every day – I’ll
never get over it – woe is me”, that
could lead me in one direction. But if
I say, “Yes, I’m glad I can take this
pill and be able to do most of the
things I want to because the pill keeps
CML at bay”, that can lead in another
direction?
Dr. Heiland: Yes. Although, I don’t
think we can keep the negative
thoughts from occurring. It is the
ability to be aware of the negative thought
and then do something about it. Cognitive
theory gives us tools to work with to
manage those negative thoughts and
evaluations of negative thoughts.
There is another direction too –
mindfulness practice. Mindfulness is consistent
with cognitive theory in many
ways. The focus of mindfulness is to
become aware of harmful mental
processes, as in cognitive theory.
However, with mindfulness, one attempts
to develop acceptance or kindness toward
oneself and for the thoughts without
judgment of those thoughts.
So the difference between cognitive theory
and mindfulness is that cognitive theory
provides a framework for changing
thoughts, challenging them in some way.
The mindfulness approach would focus on
the practice of awareness and acceptance
for the thoughts. You might say the
cognitive approach is change-based and
the mindfulness approach is acceptancebased.
Both are useful.
CML News: We’ve been doing some
mindfulness training in our leukemia support
group (or meet-up as we call it in the
Asian Group). In talking with some of the
other group members when you weren’t
around, we very much appreciate that.
Dr. Heiland: Thank you. I appreciate that
feedback. In mindfulness, we learn to
accept, with kindness, our negative
thoughts. We try not to expand on
negative thoughts or push them away.
We simply try to become aware of
them and accept our mental processes
with kindness. It seems that when we
do so, we are able to release them
without effort. When we become
aware of a tense muscle in our bodies,
we instinctively and automatically
relax that muscle. There is no thought
about why the tension is there, we
simply relax. The same is true with
mindfulness: I come to realize that a
particular thought isn’t helpful, so I
simply drop it. That is the goal. I’m
not saying it is easy. It takes practice.
CML News: No, it isn’t easy, it takes
practice. I’m finding it very helpful.
You’ve defined depression and
described some of the causes and the
theories about depression. There are
certain antidepressants that can be
used to assist in the treatment in
depression. Some of our members,
for one reason or another, don’t have
access to or can’t afford antidepressants.
Is there anything a patient can
do to help themselves with a depressive
period? Obviously, there are
cases where medication is the route
that needs to be taken, where the
chemicals in the brain are out of
balance, for example. But what are
some of the things we can do that
don’t include medication?
Dr. Heiland: Well, psychotherapy.
CML News: There are the cost and access issues again.
Dr. Heiland: Of course. One of the simpler but more profound
things that can be done is what Dr. Teri Woods, a psychologist
here at the UW teaches us, that is, radical self-care.
CML News: Yes, I’ve known Teri for 9 years. She cofacilitates
A View Beyond, the gynecological cancer support
group I’ve been a member of since 1997. I’ve also talked to
her one on one about some of the issues surrounding my
CML journey and other things in my life. She’s talked to me
several times about radical self-care.
Dr. Heiland: Yes, radical self-care involves engaging in
behaviors that are nurturing and meaningful; and that will go
a long way to help. Many people have tremendous compassion
for others but find it difficult to have compassion for
themselves and to nurture themselves. Radical self-care is an
extension of compassion for oneself. Radical self-care is
healing to us. Let me talk a bit more about mindfulness. It is
learning to have compassion and kindness toward ourselves
in the present moment. In a sense, mindfulness is an attempt
to develop intimacy and a sense of safety with the self, no
matter what is experienced.
Mindfulness and radical self-care are consistent with the
integrative theory that I spoke of earlier. We try to
engage in behaviors that are positive reinforcements,
becoming aware of our thoughts, both negative and
positive, and having compassion and kindness towards
ourselves for those thoughts. Of course, finding
something meaningful to do is important too.
CML News: I know for many in our group, (and I hate to
use the phrase) ‘the blessing of cancer,’ has caused us to
find out what is meaningful and important to us and have
learned to let the other stuff go. Having a cancer
diagnosis can lead us to put what is the most important on
the top of the priority list.
Dr. Heiland: You don’t want to waste a moment or live
without paying attention.
CML News: Right. It’s too bad everyone can’t learn that
lesson without having a cancer diagnosis. Some people do, but many of us don’t until
the life-threatening event takes place.
Dr. Heiland: I think that a health-related crisis can
facilitate that growth. Some of the day-to-day stuff just
drops away and is no longer relevant. The experience of
CML, or other types of cancer, can facilitate growth.
CML News: If you were to read many of the posts of our
group, you would see that many of us have learned that
lesson and we share with each other what we’ve learned. Is
there anything that we haven’t discussed that you want to
mention?
Dr. Heiland: One thing I haven’t mentioned is that when a
person becomes depressed, it is all consuming. It is as if one
feels that depression is all there is to life. One of the goals
of treatment is for the individual to realize that they are
more than the depression; that depression is something that
they experience but it is not intrinsically a part of them.
Depression is something that can be managed and overcome.
Also, I don’t want to downplay the importance of medication
to treat depression. However, research has shown that the
combination of medication and psychotherapy is the most
effective treatment for depression. I think it is important to
learn new skills to manage depression.
CML News: Thank you, Dr. Heiland, for taking time to talk
with us today and give us some insight into depression and
CML. I’ve learned a lot during the interview and I know the
group will too.
| Dr. Mark Heiland is a psychologist who works exclusively with cancer patients at the University of Wisconsin Hospital and Clinics in Madison, WI, USA. He co-facilitates a leukemia support group at the UW along with Claudia McGonigle, a CML patient and member of the Asian CML Support Group. In this article, Claudia interviews Dr. Heiland on his insights on depression in cancer patients. Interview conducted: November, 2006 |