Books


Coping with Depression

Chapter Contents

Understanding the Problem
Depression is common among persons with cancer
How a person acts when depressed
Causes of depression
What you can do as a caregiver
Family and friends can also become depressed

When To Get Professional Help
Symptoms that indicate that professional help is needed
How to get professional help
What You Can Do To Help
Taking care of your own emotional needs when living with a depressed person
How to react to a person who is depressed
How to prevent or decrease depression

Possible Obstacles
"I don't want your help."
"It's normal to be depressed in my situation."
"It's no use trying."
Carrying Out and Adjusting Your Plan
Work as a team
Use these techniques early
Plan in advance and persist
Talk regularly with him or her about feelings
Watch to see if professional help is needed
Don't expect change too fast

Techniques for Controlling Negative Thoughts
Thought stopping
Arranging a time and place for negative thinking
Distraction
Arguing against negative thoughts
Solving day-to-day problems that are causing stress
(Topics with a in front of them are actions you can take or symptoms you can look for.)

[The information in this home care plan 
fits most situations, but yours may be 
different. If the doctor or nurse tells 
you to do something else, follow what they
say.]

The person with cancer is the one who will
use the techniques in thishome care plan. 
Your job is to help him or her make the 
best use ofthese techniques. The person 
with cancer should read this plan, and
then the two of you should work together 
as a team. You can also use
these techniques to control your own 
depression.

Understanding the Problem

The stress of dealing with an illness like cancer can cause many uncomfortable feelings such as depression. Sometimes we are able to get over "the blues" after a short time. But sometimes these feelings last a long time and can severely hurt the quality of a person's life. When a person is sad, discouraged, pessimistic, or despairing for several weeks or months, and when these feelings interfere with being able to manage day-to-day affairs, we say that he or she is suffering from depression. Depression can last a long time if the person doesn't do something to stop it.

In addition to feelings of sadness, the symptoms sometimes include problems with appetite, sleeping, having the energy to do things, and problems paying attention to things. Alcohol abuse, especially if it is new or worse since the illness, may be a sign of depression. Sometimes a depressed person also thinks about suicide as a way out.

If the person with cancer is depressed, he or she will have problems coping with their illness and the impact it has on their life.

Depression works like a downward spiral. The person feels down, so he or she doesn't put energy into solving problems. When the problems get worse, they can cause the person to feel worse. And so on and so on. Somehow this has to be interrupted. Some kind of change has to happen, or the person will have these feelings for a long time.

Depression can be a side effect of some medicines, or it can be caused by chemical imbalances in the body due to the cancer. When this happens, changes in medical treatments may help the depression.

In this home care plan, we discuss some ways to tell when a depressed person must seek medical help. We also discuss some ways that you can help a depressed person limit or manage depression. Your help is valuable to a person feeling depressed, but it is also important that he or she practice certain self-help strategies. We discuss ways that you and the person with cancer can work together as a team to deal with depression.

Some depression is a normal response to the stresses and uncertainties of chronic illness. Don't expect to get rid of all of these feelings. However, you can help to limit the length and severity of depression.

As a caregiver, you can help prevent feelings of sadness or discouragement from becoming severe or continuing for long periods of time. Working as a team will help both of you keep depressed feelings under control. If the symptoms become severe, you can help the person with cancer get professional help.

(Living with a person who is depressed can be stressful and can even lead to your becoming depressed. It is important to pay attention to your own emotional health if you are to do your best as a caregiver.)

Your goals are to:

work as a team with the person with cancer to manage depressed feelings and thoughts,

keep an eye out for early depressive symptoms and help the person with cancer to manage depression early before the symptoms become severe, and

take care of your own emotional needs when living with a person who is depressed.

When To Get Professional Help

Symptoms that indicate that professional help is needed

If any of the following is occurring, you should get assistance from a health professional.

He or she is talking about hurting or killing him- or herself.
Suicide is not common among persons with cancer, although anyone who talks about suicide should be taken seriously. If you are not sure, ask if he or she is thinking about suicide. Your asking won't make it more likely. If you think there is a possibility of suicide, this is a problem that requires professional assessment and help. Although it may be uncomfortable for you, you should seek professional assistance as soon as possible.

He or she has been depressed before this illness and has had at least two of the following symptoms consistently during the past 2 weeks:

  1. Feeling sad most of the day

  2. Loss of interest in almost all daily activities

  3. Difficulty paying attention to what he or she is doing and trouble making choices.
A person with a history of serious depression before the illness is vulnerable to depression after a major life stress. A serious illness like cancer often triggers depression in these people. Professional help is usually required to help them.

You notice wide mood swings from periods of depression to periods of agitation and high energy.
Some people who have wide, uncontrollable swings in mood may have a "manic-depressive" illness. They cycle between being depressed with low energy and having a great deal of energy with feelings of agitation or feeling "high." The moods often don't seem connected to what is going on around the person. This requires professional help to determine if medication is necessary.

Nothing you do seems to help, even those strategies that have worked in the past.

How to get professional help

Getting help for depression is just like getting help for physical problems. Asking for help doesn't mean you are saying the person is crazy. The problem could be caused by the stress related to cancer or to the treatment itself. Or it could be an understandable reaction to the serious issues a person with cancer must face.

Some people are hesitant to ask for professional help with their emotional problems because they are embarrassed. They may think that seeing a psychologist, psychiatrist, or social worker means that they are weak or strange. Being upset during a major illness is normal. So is getting help for these problems. Professionals such as social workers, nurse counselors, clergy, psychologists, and psychiatrists are skilled and experienced in helping people deal with emotionally stressful experiences. They are there to help you with this kind of problem just like your family doctor is there to help with physical problems.

Ask for help from the physician who is treating the cancer, a family doctor, or another physician who is familiar with the medical treatments being given.
Physicians familiar with the person's medical condition and treatments can evaluate whether the depression is due to the disease or the treatment. If it's due to the treatment, then a change in treatment may be needed. Physicians can also evaluate whether anti-depression medications may help and can prescribe them if necessary.

Ask a mental health professional such as a social worker, psychologist, or psychiatrist for help.
Mental health professionals are experienced in helping people with many types of emotional problems. They can be especially helpful when there is a history of depression before the illness and when the depression is not due to the person's disease or treatments. Many psychologists, social workers, and other mental health professionals have experience working with people with cancer. They can be very helpful when depression is a reaction to the stress of the illness.

Changing depressed feelings takes time. It usually takes at least several sessions with a counselor or therapist before a person begins to feel better. It also takes time for medicines to work, and the doctor may need to adjust the doses before the medicines are helpful.

What You Can Do To Help

Take care of your own emotional needs when living with a depressed person.

Many people are aware that depression happens frequently among persons with cancer. But fewer people recognize that family members and friends who care for someone with cancer also often experience depression during the illness. All the stress can make a person feel "burned out." When someone feels this frustrated, he or she won't be much help to another person.

Caregiving can be stressful. To do your best in this difficult role, you need to find ways to stay emotionally well yourself. Here are some things that you can do for your own emotional health:

Understand that it is not your fault if the person becomes depressed. You should realize that you are not responsible if the person you are caring for becomes depressed.
Depression can be caused by many things, including biological changes as well as changes in his or her life. Sometimes, especially if the depression is severe, only professionals can help. You should not feel guilty if, in spite of your best efforts, the person with cancer becomes or stays depressed.

Schedule positive experiences for yourself.
Keep doing things that make you feel good. Don't become so involved in your caring responsibilities that you neglect your own emotional health. Don't feel guilty about taking care of yourself. If you become overwhelmed, you won't be able to provide care and support. You will be a better caregiver if you take time to do things that you enjoy outside of your caring responsibilities. If you start feeling overwhelmed, take time off to do the things you enjoy. Do this early. This can help prevent your becoming seriously depressed and give you the strength to carry on.

Get the companionship you need.
Remember that you need companionship. Being with others is as important for you as for the person you are caring for. Continue to do things with people you like and enjoy. This helps to prevent and manage your own "blues." If you feel yourself becoming depressed, seek out other people to talk to and do things with. Some people find it helpful to talk to other people about their problems. Others find it more helpful to talk about things that have nothing to do with their problems. This depends on how you feel and on the person you are talking to.

You can get professional help for yourself, too, if necessary.

How to react to a person who is depressed

Acknowledge that the person is depressed.
One thing you should not do is to ignore the person's depression. Sometimes people act as if the depression weren't there, either because they don't want to encourage it or because they don't want to deal with it. This is wrong! It is uncomfortable to acknowledge that someone you care for is depressed, but ignoring depression only makes it worse. The depressed person may feel that you do not care.

You can be of most help early-before depression becomes severe. If you ignore the early signs of depression, it is more likely to get out of hand, to seriously affect the quality of life of the person with cancer, and to require professional help.

Agree with correct and positive thinking.
Help correct those thoughts that seem wrong to you (see Techniques for Controlling Negative Thoughts at the end of this home care plan).

Of course, some of the depressed person's thoughts are correct. You should make clear that you accept and agree with the correct parts. You are only disagreeing with the parts that seem wrong. You can point out, in a supportive way, the incorrect thoughts.

A depressed person might say, "Nothing is going right." But there is usually something that is going okay. You can say, "I understand you're feeling discouraged, but let's think of some of the things that are going right."

The depressed person might say, "I'm a total failure." But you know that his or her whole life is not a failure. You might then say, "Maybe you've failed at some things, but think of all the things you have accomplished"-and then talk about several of them.

Encourage him or her to discuss the depression with a physician who understands the treatments being received or with a mental health professional.
See the discussion on asking for help from the physician who is treating the cancer in the section How To Get Professional Help in this home care plan.

How to prevent or decrease depression

Much of the work here has to come from the person with cancer. In this section, we describe a variety of methods that he or she can use to prevent or decrease depression. Both you and the person with cancer should read them carefully. If he or she cannot or does not want to read this plan, then explain the ideas and how you can help. These techniques work for most people. Your primary role is to be a team member by helping your loved one learn these strategies and then by being supportive and encouraging their use.

Help increase the number of pleasant, involving experiences for the person with cancer.
The home care plan for Maintaining Positive Experiences guides you in planning and carrying out three types of enjoyable activities: activities with other people, activities that give a sense of accomplishment, and activities that make the person feel good. Use that home care plan as part of your efforts to help the person with cancer combat depression.

Help increase the number of activities that the person with cancer does with other people. Being with people you know and enjoy is an excellent way to take attention away from negative thoughts and feelings. It provides opportunities to think about one's own life in comparison to others and to recognize the good things in one's life. It provides opportunities to give as well as to receive help, to share experiences and perspectives, and to get help in dealing with problems that are making the person with cancer depressed. Most important is that other people can express caring and love for the person with cancer. Knowing that other people care and are available to help when needed gives people strength and confidence when facing an uncertain future.

Three types of people can be especially helpful for persons with cancer. Make a list of friends and family members using the following categories. Then use the home care plan for Getting Companionship and Support from Family and Friends to think of ways to be with these people.

  1. People who are sympathetic and understanding

  2. People who give good advice and who can help solve problems

  3. People who can turn his or her attention away from problems and toward pleasant experiences.
The home care plan for Getting Companionship and Support guides you in developing plans to increase support and help from other people.

Encourage him or her to set reasonable, attainable goals.
Depressed people tend to set goals that are too high, and when they don't reach their goals, they tend to become even more depressed. When you plan positive experiences, be sure that your goals are reasonable. It is better to set a low goal and accomplish more than you expected than to set too high a goal and fail.

Support his or her efforts to control repetitive, negative thoughts and to substitute positive experiences and thoughts.
When the person with cancer tells you that he or she needs to do something to "break out" of depressive thoughts, you can help by encouraging and becoming involved in the activities. This can be as simple as talking about something pleasant or doing an activity together.

Five techniques for controlling negative thoughts are explained at the end of this home care plan. They are:

  1. Thought stopping-to control repetitive negative thinking

  2. Arranging a plan and time for negative thinking-to control and limit negative thoughts

  3. Distraction-to take attention away from negative thoughts

  4. Arguing against negative thinking-to show yourself how unreasonable your negative thoughts are

  5. Solving day-to-day stressful problems that can be a cause of negative thoughts.
Make a plan to let the person with cancer know when you think he or she is doing things which may lead to depression.
This helps him or her to manage the depression early, before it becomes severe. Some people find it easiest to use a code word or phrase that the two of you agree on to point out depressed thinking. However you do it, a gentle reminder for him or her to stop and think about negative thoughts and unrealistic goal setting can help give a way to prevent the depression from setting in.

Possible Obstacles

Think about obstacles that could stop you from carrying out your plan and about how you will deal with them.

Here are some obstacles that other people, like yourself, have faced in helping a person with cancer deal with depression

1. "I don't want your help. Leave me alone."

Response: Explain that you can't do anything without cooperation. He or she must participate in the home care plan if it is going to be effective. Explain that you will not do anything without his or her agreement and cooperation. Next, have him or her read this home care plan. Discuss it together and agree on what you will try first. Start small-with something that is easy to do-and then evaluate the results. If the depression is so severe that the person with cancer doesn't even want to try, professional help may be needed.

2. "My problems are real! It's normal to be depressed in my situation."

Response: Agree that the problems are real and some depression is normal. But suggest that getting stuck in the feeling of depression can interfere with dealing with the problems that are causing the depression. Explain that the goal is to keep a balance between positive and negative thoughts. The problems are real, but many of the good things in life are also real and should get equal attention.

3. "Nothing will help, so it's no use trying."

Response: Urge him or her to give it a try! There is nothing to lose and a good deal to gain. Start with things that are easiest to do. Then judge if these ideas are helpful. If the person with cancer is so depressed that he or she can't even try, then professional help is probably needed.

Think of other obstacles that could interfere with carrying out your plan.

What additional road blocks could get in the way of doing the things recommended in this home care plan? For example, will the person with cancer cooperate? Will other people help? Do you have the time and energy to carry out the plan?

You need to develop plans for getting around these road blocks. Use the four COPE ideas (creativity, optimism, planning, and expert information) in developing your plans. See the chapter on Solving Home Care Problems at the beginning of the book for a discussion of how to use the four COPE ideas in overcoming your obstacles.

Carrying Out and Adjusting Your Plan

Carrying out your plan

Talk this plan over with the person with cancer.
Together you should agree on what you can do together to manage depression. It is important to work as a team when dealing with these problems. Sometimes the support and the feeling of being on a team is in itself helpful to a depressed person.

Use these techniques early.
Look for beginning signs of depression and put your plan into action then-don't wait until depression is severe. The techniques discussed in this plan have helped severely depressed persons, but usually as part of professional treatment. As a caregiver, you can help most before depression becomes severe.

Plan in advance what you will do to manage depression.
If you know that the person with cancer is likely to be depressed at certain times based on past experience, then make plans for what you will do to prevent depression from building up.

Persist. Even if the person with cancer continues to feel depressed, don't give up.
You are probably preventing the depression from getting worse. Keep working cooperatively with the depressed person. If you are working together, these ideas can only help.

Checking on results

Talk regularly with the person with cancer about his or her feelings.
Although it may be difficult for you at first, let the person with cancer know that you understand that depression can happen during this illness. If you show that you are comfortable talking about feelings, the person with cancer is more likely to let you know early on if he or she is experiencing depressive symptoms.

It may seem scary at first to talk to a depressed person about what is upsetting him or her. But it's important to do this because it shows that you care, and it helps you to work together, as a team, to control the depressed thoughts and feelings.

Watch for indications that professional help is needed.

If the plan doesn't work

Ask if you are expecting change too fast. It usually takes time to manage depression. Look for a small improvement at first. Remember: Your efforts may be successful even if they just keep the depression from getting worse.

If these techniques do not seem to be helping and the person with cancer has been feeling very depressed for several weeks, review this home care plan to be sure you have tried all of the ideas. If so, you should encourage the person with cancer to seek professional help.

Techniques for Controlling Negative Thoughts

Thought stopping

One of the hard things about depression is that it's so easy to get stuck in a whirlwind of negative thinking. Suddenly you may find depressing thoughts going around and around in your head. It doesn't take long for this to make you feel bad; and then it may seem like you can't stop it. But you can!

The thought-stopping technique helps you to "snap out of it" when that whirlwind of negative thoughts first starts. If you catch it early, you can keep it from getting you too upset. The trick is to do this when you first notice a negative thought.

When you first feel yourself in the negative-thinking whirlwind, try one of these techniques:

Yell "STOP" really loudly in your mind.
Yell STOP when you scream STOP in your mind; pretend it is very loud. The idea is to wake you up, to make you aware that you're in danger of getting stuck in negative thoughts. You might start this by going to a place by yourself and shouting STOP out loud. Practice it this way until you can do it in your mind alone.

Visualize a big red STOP sign.
Try to see it clearly, and then get your mind on something else. Think of what a STOP sign looks like. Make sure you see it as a red sign. Practice seeing it in your mind so that you can bring it to mind easily. Now whenever you catch yourself starting negative thoughts, think of this image and stop yourself.

Slap yourself on the wrist with a rubber band.
Another way to remind yourself to stop is to gently slap your wrist with a rubber band. This isn't to punish yourself. It's to give you a physical reminder to stop the thoughts.

Splash some water on your face.
Splashing water in your face is another way to wake yourself up from the negative thinking. Pay attention to how the water makes you feel. And stop your negative thoughts.

Get up and move to a new spot.
Getting up and moving to a new spot gives you a change of scenery. You can use the new surroundings to help you think about other things.

You have to fight the negative thoughts. Maybe several of these techniques together will work for you.

When you're depressed, you may look at techniques for stopping these thoughts and say, "That's silly. It could never work." Actually, research has shown that they can work. Give them a try!

Arranging a time and a place for negative thinking

This technique allows you to think about negative things, but puts you in control of when and where you do this thinking.

Find a negative-thinking "office."
This can be a room, a chair, or just a certain window. Make this the only place you let yourself think about all of the negative things.

Your "office" space can be any place you choose. Don't, however, make it your bed or your seat where you eat. These need to be "safe zones." Now you should try to only think your negative thoughts in this one place.

Schedule a time each day when you plan to think your negative thoughts.
Scheduling a time to think about your negative thoughts helps you to take control of them. You might not be able to control all negative thinking, especially in the beginning. But this technique will gradually help you to get control over your negative thinking.

Don't make this time around mealtimes, just before you go to sleep, or just before you expect to see people. These should be relaxing times. Make this time no more that 15 minutes. At the end of 15 minutes, stop. You can continue tomorrow.

Distraction

You can't think two things at once. When you start thinking negative thoughts, get your mind involved in another activity which "pushes out" or replaces the negative thinking. Try one of these ideas:

Take a vacation in your mind.
Close your eyes and think about your favorite spot. Spend a couple minutes there on a mental vacation. Relax and enjoy it.

Mental time travel into the future.
Think of something that you are looking forward to. Imagine that it is happening. Think of how nice it is to be there.

When you take your mental vacation or time travel to something you're looking forward to, really try to work your imagination. Think about as many details as possible.

What does it feel like? Is it a warm breeze? Imagine how it feels on your skin.

What does it sound like? Are there waves gently crashing on the beach? Are people laughing, or is music playing? Imagine it as clearly and vividly as you can.

What does it look like? Is the sky clear and blue? Or are you in a room? Imagine what the room looks like. Try to see it as completely as you can.

What does it smell like? Is it the salty smell of the ocean? Maybe you smell the fragrances of a garden or a big dinner. Make it as clear as you can.

What does it taste like? Are you drinking a nice cool drink? Feel it in your mouth. Taste it.

Use these exercises to fill your mind with as many pleasant details as you can. Think of as many as you can. This exercise is also helpful when you are feeling anxious and need help falling asleep.

Tension busting. Use the relaxation exercises in the home care plan for Coping with Anxiety.
Being relaxed helps you to think about pleasant things.

Do something you like.
Use the home care plan on Maintaining Positive Experiences. Really get yourself involved in an activity you like.

The idea of this exercise is to fill your mind up with positive thoughts and to have them crowd out the negative ones.

Arguing against negative thoughts

The idea of this exercise is to make yourself see both sides of the picture. Things aren't usually as bad as they first seem when you're depressed. But the only way to see the other side is to actively argue against it.

You can fight your negative thoughts. Challenge their accuracy. Every situation has at least two sides to it. When you're depressed, you probably only see the bad side. If you weren't depressed, you would usually think of both sides. This exercise forces you to actively take the other side. It is like having a debate with yourself.

Is your negative thought really true? Make yourself be clear about what evidence supports it.
Now take the other side. Argue the exact opposite.
Think of every reason why your thought may not be true or may be exaggerated. Don't give up too easily. Really argue as if you were arguing with someone else.

When you're arguing with your negative thoughts, try to be as complete as possible. You may want to write down the answers to the following questions:

What is the evidence against my negative thought?

Are there any "facts" in my thinking which are really just assumptions?

Is my argument an example of "black and white" thinking? Are there shades of gray that I'm ignoring?

Is the negative side taking things out of context? Am I looking at the whole picture or just one small part of it?

Am I trying to predict the future, when I really know that I can't?

Try to punch as many holes in your "negative sides" argument as you can. Don't accept any illogical thinking at all.

Solve day-to-day problems that are causing you stress

Use a problem-solving approach to solving some of the day-to-day problems that are contributing to your feelings of depression, such as finding enough time to do housework, problems with family members, and so on.

The home care plan on Solving Home Care Problems at the beginning of this book [not published on OncoLink] explains how to use four problem-solving steps to deal with problems that are not included in this workbook. The four steps are:

Get information from cancer care experts about the problem and what you can do (the kind of information that is in the home care plans).
Develop your plan in an orderly way, including reviewing the facts, setting reasonable goals, and choosing the strategies that are the best balance between risk and benefit.
When you encounter obstacles, you should:

Keep a positive outlook, and
Be creative by seeing the problem from someone else's perspective, asking other people for ideas, and rethinking your expectations.

You can remember these ideas with the word COPE:

C for being Creative
O for being Optimistic
P for Planning and
E for using Expert information.




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