Depression

Managing depression can help you maintain your daily activities and relationships and improve your quality of life. Reducing depression can boost your ability to make skillful choices about your care and cope with cancer treatment.

Depression at a glance

Depression—a mood disorder that causes a persistent feeling of sadness and loss of interest—is common among people with cancer. Depression is linked to some body terrainthe internal conditions of your body, including nutritional status, fitness, blood sugar balance, hormone balance, inflammation and more factors related to cancer, and even to cancer outcomes. Identifying and managing depression may be important in your cancer treatment plan.

Symptoms include sadness, loss of motivation or interest in activities,  trouble focusing or making decisions, and many more. Triggers for depression include feelings of grief, despair, anxiety, or pain. Many people have a diagnosis of both depression and anxiety.

Complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocial therapy, and acupuncture approaches can help you manage depression. Mind-body therapiesapproaches that enhance your mind’s capacity to positively affect your body’s function and symptoms. Some interventions focus on calming your mind, improving focus, enhancing decision-making capacity, managing stress, or resolving conflict. Other interventions have a goal of relaxing both your mind and your body., some supplements and natural products, and therapies that manipulate your body or bioenergy fields have been helpful for some people. Depression may also be a symptom of stress. If stress is contributing to your depression, managing your stress will be important in reducing it.

Top practices and therapies for managing depression

Therapies and practices we have reviewed

The effects of these practices and therapies are described below on this page. Full details of evidence are on the therapy reviews, accessible through the image links below.

Further therapies

Therapies recommended in clinical practice guidelines but that we haven’t yet reviewed; see belowUse your browser's Back button to return to this location. for guidelines ›

Acetyl-L-carnitine

Behavioral approaches

DHEA

Folate

Hypnosis

Lavender

Light therapy

Massage therapy

Meditation

Music and arts therapies

Omega-3 fatty acids

Saffron

S-adenosyl-L-methionine (SAMe)

Sleep deprivation

St. John’s wort

Transcranial direct current stimulation (tDCS)

Vagus nerve stimulation (VNS)

Psychosocial therapies:

  • Cognitive-behavioral therapy
  • Cognitive-behavioral stress management (CBSM)
  • Mindfulness-based stress reduction (MBSR)
  • Psychoeducation
  • Supportive/expressive therapy

Other therapies

Seeveral other therapies have some evidence of benefit. The benefit may be meaningful or even substantial, but our reviews show the evidence so far is preliminary.

Acupuncture

Electroacupuncture

Healing touch

Melatonin

Polarity therapy

Reiki

Reishi mushroom

Support groups

Seek professional help if needed. Diagnoses such as depression can require therapy from trained practitioners for management. We encourage you to explore the options available to you through your cancer team and others. Taking care of your mental health is as important as taking care of your physical health.

On this page

What is depression?

Depression is a treatable mood disorder that causes a persistent feeling of sadness and loss of interest.1Mayo Clinic. Depression (major depressive disorder). Viewed July 15, 2021. About one in four people with cancer experience severe depression.2National Cancer Institute. Depression PDQ: Health Professional Version. June 10, 2021. Viewed July 15, 2021. Some people may already have been depressed before learning they have cancer, and having cancer may affect their depression. 

Prolonged or severe depression can interfere with your functioning. “Depression may make it harder to cope with cancer treatment. It may also interfere with your ability to make choices about your care. As a result, identifying and managing depression are important parts of cancer treatment.”3Cancer.Net. Depression. American Society of Clinical Oncology. April 2016. Viewed July 15, 2021. 

Severe depression, called major depressive disorder or major depression, affects relationships and day-to-day life and makes functioning difficult.4Cancer.Net. Depression. American Society of Clinical Oncology. April 2016. Viewed July 15, 2021; American Cancer Society. Depression. February 1, 2020. Viewed July 15, 2021. 

What are the signs or symptoms of depression?

Suicidal thoughts

If you have suicidal thoughts, inform your physician or mental health provider as soon as possible. If you consider acting on suicidal thoughts, seek medical help immediately.

National Suicide Prevention Lifeline

In the US, this lifeline is open 24 hours a day, seven days a week, at 800-273-8255.

Access the website

International Association for Suicide Prevention

This website provides information on crisis centers and helplines around the world.

Access the website

If you are a caregiver or loved one to someone you suspect or who openly tells you they’re having suicidal thoughts, you can help. 

American Foundation for Suicide Prevention

An excellent guide for what you can do if a loved one indicates they are having suicidal thoughts

If Someone Tells You They’re Thinking About Suicide: A #RealConvo Guide from AFSP

Guidance from AFSP if your loved one is in immediate danger:

  • Stay with them
  • Help them remove lethal means
  • Call the National Suicide Prevention Lifeline: 1-800-273-8255
  • Text TALK to 741741to text with a trained crisis counselor from the Crisis Text Line free of cost, 24/7
  • Encourage them to seek help or to contact their doctor or therapist

Other signs and symptoms of depression

People experiencing depression may show physical, behavioral, and cognitive (thinking, analyzing, or problem-solving) symptoms. Symptoms of depression may appear right after a cancer diagnosis or any time during or after treatment. Symptoms range from mild to severe. 

Tell your care providers if you experience these, especially if you experience several and/or they last two weeks or longer.5Cancer.Net. Depression. American Society of Clinical Oncology. April 2016. Viewed July 15, 2021.

Mood-related symptoms
  • Feeling down
  • Feeling sad
  • Feeling hopeless
  • Feeling irritable
  • Feeling numb
  • Feeling worthless
  • Feeling anxious
Cognitive symptoms
  • Trouble focusing
  • Difficulty making decisions
  • Memory problems
  • Negative thoughts. In extreme situations, these may include thoughts that life is not worth living or thoughts of hurting yourself.
Behavioral symptoms
  • Loss of interest in activities that you used to enjoy
  • Frequent crying, or crying without provocation
  • Withdrawal from friends or family
  • Loss of motivation to do daily activities
Physical symptoms
  • Fatigue
  • Appetite loss
  • Inability to fall asleep or stay asleep (insomnia)
  • Feeling very sleepy most of the time (hypersomnia)
  • Excessive sleeping during the day
  • Sexual problems, such as lower sexual desire

Because cognitive and physical symptoms may be side effects of your cancer or cancer treatment, doctors place more emphasis on mood-related and behavioral symptoms when diagnosing depression with cancer.6Cancer.Net. Depression. American Society of Clinical Oncology. April 2016. Viewed July 15, 2021.

What may cause or trigger depression?

According to the National Cancer Institute, “Sadness and grief are normal reactions to the crises faced during cancer. All people will experience these reactions periodically. Normally, a patient’s initial emotional response to a diagnosis of cancer is brief, extending over several days to weeks, and may include feelings of disbelief, denial, or despair.”7National Cancer Institute. Depression PDQ: Health Professional Version. June 10, 2021. Viewed July 15, 2021.

Depression can be triggered by an anxiety disorder, and many people have a diagnosis of both depression and anxiety ›8Sawchuk CN. Depression and anxiety: Can I have both? Mayo Clinic. June 2, 2017. Viewed July 19, 2021.

Some medications are connected to depression, such as these.9National Cancer Institute. Depression PDQ: Health Professional Version. June 10, 2021. Viewed July 15, 2021.

  • Steroids
  • Propranolol
  • Interleukin-2a biological response modifier used as immunotherapy to boost the immune system in cancer therapy; also called IL-2 (IL-2)
  • Barbiturates
  • Some antibiotics
  • Some chemotherapy drugs

Risk factors

You are more likely to experience depression if you have these risk factors.10Cancer.Net. Depression. American Society of Clinical Oncology. April 2016. Viewed July 15, 2021; Hammen C. Risk factors for depression: an autobiographical review. Annual Review of Clinical Psychology. 2018 May 7;14:1-28; Torquati L, Mielke GI, Brown WJ, Burton NW, Kolbe-Alexander TL. Shift work and poor mental health: a meta-analysis of longitudinal studies. American Journal of Public Health. 2019 Nov;109(11):e13-e20; Roman M, Irwin MR. Novel neuroimmunologic therapeutics in depression: a clinical perspective on what we know so far.Brain, Behavior, and Immunity. 2019 Sep 21. pii: S0889-1591(19)30536-7; Iguacel I, Huybrechts I, Moreno LA, Michels N. Vegetarianism and veganism compared with mental health and cognitive outcomes: a systematic review and meta-analysis. Nutrition Reviews. 2021 Mar 9;79(4):361-381; Okuyama M, Takaishi O et al. Associations among gastroesophageal reflux disease, psychological stress, and sleep disturbances in Japanese adults. Scandinavian Journal of Gastroenterology. 2017 Jan;52(1):44-49.

  • Stressful life events and circumstances, including financial burdens
  • Family history of depression or anxiety
  • Previous diagnosis of depression or anxiety
  • Interpersonal dysfunction
  • Lack of support from friends and family
  • Being female
  • Shift work
  • Inflammation
  • Vegan/vegetarian diet, possibly due to a deficiency of some B vitamins11Hall-Flavin DK. Vitamin B-12 and depression: Are they related? Mayo Clinic. June 1, 2018. Viewed May 20, 2022.
  • Gastroesophageal reflux disease (GERD)

Pain may worsen depression, and depression may worsen pain.12Charalambous A, Giannakopoulou M, Bozas E, Paikousis L. Parallel and serial mediation analysis between pain, anxiety, depression, fatigue and nausea, vomiting and retching within a randomised controlled trial in patients with breast and prostate cancer. BMJ Open. 2019 Jan 24;9(1):e026809; Joyce C, Roseen EJ, Keysor JJ, Gross KD, Culpepper L, Saper RB. Can yoga or physical therapy for chronic low back pain improve depression and anxiety among adults from a racially diverse, low-income community? A secondary analysis of a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2021 Jun;102(6):1049-1058; Ciaramella A, Poli P. Assessment of depression among cancer patients: the role of pain, cancer type and treatment. Psycho-oncology. 2001 Mar-Apr;10(2):156-65. Alleviating either depression or pain to interrupt the feedback loop between them may provide relief from both symptoms.

Why is managing depression important?

From The Ecology of Breast Cancer:13Schettler T. The Ecology of Breast Cancer: The Promise of Prevention and the Hope for Healing. 2013. Science and Environmental Health Network and the Collaborative on Health and the Environment p. 80.

Depression is not only important psychologically but also can increase inflammation and alter some immune system functions.14Cohen L, Cole S, Sood A et al. Depressive symptoms and cortisol rhythmicity predict survival in patients with renal cell carcinoma: role of inflammatory signaling. PLoS One. 2012;7(8):e42324. This can promote conditions for tumor growth, invasion, and metastasis.

Depression is linked to body terrainthe internal conditions of your body, including nutritional status, fitness, blood sugar balance, hormone balance, inflammation and more factors important in cancer, and to higher risks of cancer, of recurrence, and of cancer-related death.

The nature of these links may be complex. Depression may lead to worse health, or inflammation, poor health, and approaching death may contribute to depression. The link may work in both directions.

Since we have good evidence of these links, managing your depression may be one step you can take to improve your outcomes.

Depression and cancer outcomes

Good evidencesignificant effects in one large or several mid-sized and well-designed clinical studies (randomized controlled trials (RCTs) with an appropriate placebo or other strong comparison control or observational studies that control for confounds) (this is the CancerChoices definition; other researchers and studies may define this differently) of increased risk of cancer among people with depression

Good evidence of higher risk of recurrence among people with depression

Good evidence of higher risk of cancer-specific and all-cause mortality among people with depression

Modest evidencesignificant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observational studies), or several small studies aggregated into a meta-analysis (this is the CancerChoices definition; other researchers and studies may define this differently) of better adherence to prescribed anticancer medications among people with breast cancer without depression

Depression and your body terrain

Modest evidence that depression is linked to immune function

Good evidence that depression is linked to inflammation

Resource

What approaches can help me manage depression?

We present many approaches to reducing depression and the evidence regarding their effectiveness. Depression may also be a symptom of stress. If stress is contributing to your depression, managing your stress will be important in reducing it.

Conventional approaches

Prescription drugs and psychotherapies may help manage depression. Ask your doctor for recommendations, but also ask about side effects of drugs.

Self-care approaches

Eating Well: strong evidence

Moderate improvements in depressive symptoms among people following the recommended diet patterns of increasing vegetables and fruits, nuts, and fiber, and reducing fat, salt, sugar, and cholesterol (strong evidence)consistent, significant effects in several large (or at least one very large) well designed clinical studies or at least two meta-analyses of clinical studies of moderate or better quality (or one large meta-analysis) finding similar results (this is the CancerChoices definition; other researchers and studies may define this differently)

Recommended in a practice guideline for managing depression; see belowUse your browser's Back button to return to this location. for guidelines ›

Moving More: mixed evidence

Less depression among people participating in exercise without regard to treatment phase (strong evidence)

Less depression among people participating in exercise during cancer treatment (preliminary (conflicting) evidence)significant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently)

Less depression among people participating in exercise after cancer treatment (good evidence)

No evidence of an effectoverall, one or more studies did not demonstrate that a treatment or intervention led to an expected outcome; this does not always mean that there is no effect in clinical practice, but that the studies may have been underpowered (too few participants) or poorly designed. Larger, well-designed studies provide more confidence in making assessments. on depression among adults with advanced lung cancer participating in exercise training in a combined analysis of studies

Recommended in clinical practice guidelines for managing depression; see belowUse your browser's Back button to return to this location. for guidelines ›

Combining Eating Well and Moving More may provide even more benefit.

Less depression among women with overweight or obesity participating in an intervention of physical activity and/or diet (modest evidence)

Managing Stress: good evidence

Lower depression among people with better acceptance of cancer (good evidence)

Stress and depression are closely linked, and depression triggers may also be stressors. Therapies and approaches that manage stress may also relieve depression.

Recommended in a practice guideline for managing depression; see belowUse your browser's Back button to return to this location. for guidelines ›

Sleeping Well: modest evidence

More depression among people with breast cancer or prostate cancer with poorer sleep quality (modest evidence); improving sleep quality may lead to less depression

Creating a Healing Environment: preliminary evidence

Less depressed mood among women with moderate-to-severe premenstrual syndrome / premenstrual dysphoric disorder not using hormonal contraceptives treated with morning light therapy high in bright and blue light (preliminary evidence)

Sharing Love and Support: modest evidence

Less depression or hopelessness among people with higher levels of social support (modest evidence)

Complementary approaches

We present complementary therapies supported by evidence for managing depression. Those with the best evidence are presented first. Details of research evidence are on our reviews of each therapy.

A therapy may show a stronger effect or have more evidence in some situations than in others.

Good or modest evidence of benefit

Good evidencesignificant effects in one large or several mid-sized and well-designed clinical studies (randomized controlled trials (RCTs) with an appropriate placebo or other strong comparison control or observational studies that control for confounds) (this is the CancerChoices definition; other researchers and studies may define this differently) indicates a relatively high degree of confidence that the therapy is linked to the outcomes as noted. Modest evidencesignificant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observational studies), or several small studies aggregated into a meta-analysis (this is the CancerChoices definition; other researchers and studies may define this differently) means several smaller or at least one large study have found the effect described.

Acupressure: modest evidence

Less depression among people with cancer treated with acupressure (modest evidence)

Guided imagery: modest to weak evidence

Guided imagery is often used with other mind-body therapiesapproaches that enhance your mind’s capacity to positively affect your body’s function and symptoms. Some interventions focus on calming your mind, improving focus, enhancing decision-making capacity, managing stress, or resolving conflict. Other interventions have a goal of relaxing both your mind and your body..

Less depression, better mood, or less negative emotions during chemotherapy among people with cancer treated with guided imagery, often with other mind-body therapies (modest evidence)

Less depression during radiotherapy among people treated with guided imagery and relaxations (modest evidence)

Better mood among men undergoing surgery for prostate cancer treated with guided imagery and other mind-body therapies (preliminary evidence)

Less sadness among parents of hospitalized children with cancer participating in progressive muscle relaxation and guided imagery (preliminary evidence)

Less depression among people with breast cancer treated with guided imagery and other mind-body therapies (weak evidence)

Less depression among people with terminal cancer treated with interactive guided imagery and progressive muscle relaxation (weak evidence)

Recommended in a clinical practice guideline for managing depression; see belowUse your browser's Back button to return to this location. for guidelines ›

Mediterranean diet: modest evidence

Not specific to people with cancer: Less depression or better mood among people following a Mediterranean diet (modest evidence)

Relaxation: modest to preliminary evidence

Relaxation is often used with other mind-body therapies.

Less depression among people with cancer treated with relaxation training, sometimes with other mind-body therapies without regard to treatment phases (modest evidence)

Less depression during chemotherapy among people treated with relaxation, sometimes also with guided imagery (modest evidence)

Less depression during radiotherapy among people with cancer treated with relaxation, sometimes also with another mind-body therapy (preliminary evidence)

Less sadness among parents of hospitalized children treated with progressive muscle relaxation and guided imagery (preliminary evidence)

Less depression among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation (preliminary evidence)

Recommended in clinical practice guidelines for managing depression; see belowUse your browser's Back button to return to this location. for guidelines ›

Tai chi or qigong: modest evidence

Fewer depressive symptoms or mood disturbance among people with cancer practicing either tai chi or qigong (modest evidence)

Recommended in clinical practice guidelines for managing depression; see belowUse your browser's Back button to return to this location. for guidelines ›

Time in nature: modest and preliminary evidence

Not specific to people with cancer:

Better mood among people listening to nature-based sounds (modest evidence)

Lower risk of depression among people with more day-to-day exposure to nature (green space) (preliminary evidence)

Lower depression scores among people participating in forest therapy (preliminary evidence)

Turmeric and curcumin: modest evidence

Not specific to people with cancer:

Lower incidence of depression among people with major depressive disorder treated with curcumin (modest evidence)

Yoga: good evidence

Less depression among people with cancer practicing yoga (good evidence)

Recommended in clinical practice guidelines for managing depression; see belowUse your browser's Back button to return to this location. for guidelines ›

Therapies with preliminary or weak evidence of benefit for depression

Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) typically indicates that not much research has been published so far, although the outcomes may be meaningful. Weak evidenceone or more case studies, supported by animal evidence OR small treatment effects of limited clinical significance OR studies with no controls OR weak trends of effects (this is the CancerChoices definition; other researchers and studies may define this differently) may mean that the effects are small or that only very preliminary research has been published.

Acupuncture Learn moreSee Less
Electroacupuncture Learn moreSee Less
Healing touch Learn moreSee Less
Melatonin Learn moreSee Less
Polarity therapy Learn moreSee Less
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Further therapies used to manage depression

These therapies are used to manage depression, but we have not yet reviewed their effectiveness or safety. Many are reviewed in this article.

Complementary therapies for clinical depression: an overview of systematic reviews

Those in bold are recommended in at least one clinical practice guideline; see belowUse your browser's Back button to return to this location. for guidelines ›

Acetyl-L-carnitine

Behavioral approaches

DHEA

Folate

Hypnosis

Ketamine

Lavender

Light therapy

Massage therapy

Meditation

Music and arts therapies 

Omega-3 fatty acids

Probiotics

Psilocybin

Repetitive transcranial magnetic stimulation (rTMS)

Saffron

S-adenosyl-L-methionine (SAMe)

Sleep deprivation

Spiritual care

St. John’s wort

Transcranial direct current stimulation (tDCS)

Vagus nerve stimulation (VNS)

Vitamin D

Psychosocial therapies:

  • Acceptance and commitment therapy (ACT)
  • Cognitive-behavioral stress management (CBSM)
  • Cognitive-behavioral therapy
  • Mindfulness-based stress reduction (MBSR)
  • Psychoeducation
  • Supportive/expressive therapy

Resources for managing depression

Helpsy Health

Helpsy empowers members to take control of their health through a real-time virtual nurse support service. This service is available via mobile devices, a Helpsy website and automated phone calls.

Access the Helpsy website

How do integrative experts manage depression?

Both medical groups and integrative experts provide recommendations for managing depression. Learn more about the approaches and meanings of recommendations.

Clinical practice guidelines

2013 clinical practice guidelines from the American College of Chest Physicians make these weak recommendations with moderate quality evidence for managing depression.

Mind-body approaches as part of a multidisciplinary approach: 

Hypnosis

Meditation

Mindfulness-based stress reduction (MBSR)

Music therapy

Psychosocial approaches including cognitive behavioral therapy, relaxation training, imagery/visualization, psychoeducation, and behavioral approaches

Tai chi or qigong

Yoga

ASCO recommends that “all patients with cancer be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care…Failure to identify and treat anxiety and depression increases the risk for poor quality of life and potential disease-related morbidity and mortality.”26American Society of Clinical Oncology (ASCO). Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults With Cancer Guideline Adaptation. April 14, 2014. Viewed June 7, 2021.

2016 clinical guidelines for the management of adults with major depressive disorder Sections 4 (neurostimulation treatments) and 5 (complementary and alternative medicine treatments) include these therapies for mild to moderate major depressive disorder (MDD). These guidelines are not specific to people with cancer.

First-line therapies

Repetitive transcranial magnetic stimulation (rTMS) for patients who have failed at least 1 antidepressant)

Physical activity 

St. John’s wort

Light therapy for seasonal depression (seasonal affective disorder/SAD)

Second-line therapies

Omega-3 fatty acids

SAMe

Yoga

Light therapy

Third-line therapies

Transcranial direct current stimulation (tDCS)

Vagus nerve stimulation (VNS)

Acetyl-L-carnitine

Saffron (Crocus sativus)

DHEA

Folate

Lavender (Lavandula)

Acupuncture

Sleep deprivation

Investigational therapies

Deep brain stimulation (DBS)

Magnetic seizure therapy (MST)

Not recommended

Inositol

Tryptophan

Rhodiola rosea (roseroot)

Management recommendations:

  • Patients with cancer who are diagnosed with major depression may benefit from pharmacologic or psychosocial interventions either alone or in combination.
  • Low-intensity psychosocial interventions include structured group physical activity programs, group-based peer support or self-help programs, and guided self-help programs based on cognitive behavioral therapy (CBT), behavioral activation, or problem-solving techniques.
  • High-intensity psychosocial interventions include individual or group CBT, behavioral couples’ therapy, and individual or group supportive-expressive psychotherapies.   

The 2017 NCCN Guidelines® on Survivorship include a recommendation to develop a plan for regular physical activity and healthy nutrition as part of management and treatment of anxiety, depression, and distress.

Society for Integrative Oncology

Two guidelines discuss managing depression among people with cancer.

Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals ›

The 2009 guidelines for complementary therapies and botanicals provide these recommendations for managing mood disturbance with cancer.

Mind-body: support and psychotherapy approaches as part of a multidisciplinary approach (strong recommendation, high-quality evidence):

  • Cognitive-behavioral therapy
  • Cognitive-behavioral stress management (CBSM)
  • Support groups
  • Supportive/expressive therapy

Mind-body approaches as part of multimodality treatment (strong recommendation, moderate-quality evidence): 

  • Hypnosis
  • Meditation
  • Music therapy
  • Other forms of expressive arts therapies 
  • Relaxation techniques
  • Tai chi
  • Yoga

Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment › This set of guidelines has been endorsed by the American Society of Clinical Oncology (ASCO).27Lyman GH, Greenlee H et al. Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO clinical practice guideline. Journal of Clinical Oncology. 2018 Sep 1;36(25):2647-2655.

The 2017 Society for Integrative Oncology clinical practice guidelines regarding people with breast cancer provide these recommendations to professionals for managing depressive symptoms or mood disturbance during and after treatment for breast cancer.

High certainty that the net benefit is substantial: offer or provide this modality:

  • Mindfulness-based stress reduction (MBSR)
  • Relaxation

High certainty that the net benefit is moderate; offer or provide this modality:

  • Massage
  • Music therapy
  • Stress management
  • Yoga

Moderate certainty that the net benefit is small; offer or provide this modality for selected patients, depending on individual circumstances:

  • Acupuncture
  • Healing touch

Published programs and protocols

These protocolsa package of therapies combining and preferably integrating various therapies and practices into a cohesive design for care, programs, and approaches by leaders in integrative cancer care provide guidance for managing depression.

We do not recommend specific integrative protocols or programs but provide information for you to evaluate with your healthcare team.

Lise Alschuler, ND, FABNO, and Karolyn Gazella

Approaches are described for certain cancer types, or along with certain conventional therapy treatments, or for particular conditions including depression.

Gerald M. Lemole, MD; Pallav K. Mehta, MD; and Dwight L. McKee, MD

Lemole GM, Mehta PK, McKee DL. After Cancer Care: The Definitive Self-Care Guide to Getting and Staying Well for Patients with Cancer. New York, New York: Rodale, Inc. 2015.

These doctors present easy-to-incorporate lifestyle changes to help you “turn on” hundreds of genes that fight cancer, and “turn off” the ones that encourage cancer, while recommending lifestyle approaches to address each type.

Gurdev Parmar, ND, FABNO, and Tina Kaczor, ND, FABNO

Parmar G, Kaczor T. Textbook of Naturopathic Oncology: A Desktop Guide of Integrative Cancer Care. 1st edition. Medicatrix Holdings Ltd. 2020.

This book provides information on the treatment of 24 cancers, plus the most effective treatments of the most common symptoms affecting cancer patients while they undergo chemotherapy, radiotherapy, or surgery.

Traditional medicine

Practitioners of traditional traditional Chinese medicine and Ayurveda offer therapies and approaches to reduce depression.

Learn more about traditional medicine and how to find practitioners.

Other recommendations

Abrams DI, Weil A, editors. Integrative Oncology, Second Edition. New York: Oxford University Press. 2014.

This book by integrative medicine experts and CancerChoices advisors Donald Abrams, MD, and Andrew Weil, MD, desribes a wide variety of complementary interventions to conventional cancer care, including a chapter from the perspective of a cancer patient.

This book mentions interventions that can be helpful in managing depression, including mind-body interventions, cannabis, and—with caution about use with some chemotherapy drugs—St. John’s wort.

Explore other side effects and symptoms

Are you a health professional?

This section does not replicate the other information on this page but provides additional details or context most relevant to professionals.

Professional recommendations

A large RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects found that the Mental Health and Dynamic Referral for Oncology (MHADRO) program may increase access to mental health care, lessen hospitalizations, and improve providers’ management of psychosocial needs, but does not appear to impact overall functioning over time.28O’Hea E, Kroll-Desrosiers A et al. Impact of the mental health and dynamic referral for oncology (MHADRO) program on oncology patient outcomes, health care utilization, and health provider behaviors: a multi-site randomized control trial. Patient Education and Counseling. 2020 Mar;103(3):607-616.

Suicide among people with cancer

Although most people with cancer don’t commit suicide, their risk of suicide is twice as high as among the general population. Main findings of a 2022 review:29Chang WH, Lai AG. Cumulative burden of psychiatric disorders and self-harm across 26 adult cancers. Nature Medicine. 2022 Apr;28(4):860-870.

  • Patients who received chemotherapy, radiotherapy and surgery had the highest cumulative burden of psychiatric disorders. 
  • Patients treated with alkylating agent chemotherapeutics had the highest burden of psychiatric disorders, whereas those treated with kinase inhibitors had the lowest burden. 
  • All mental illnesses were associated with an increased risk of subsequent self-harm, where the highest risk was observed within 12 months of the mental illness diagnosis. 
  • Patients who harmed themselves were 6.8 times more likely to die of unnatural causes of death compared with controls within 12 months of self-harm. The risk of unnatural death after 12 months was markedly lower.

Daniel C. McFarland and colleagues offer some key points for knowing which cancer patients are particularly at risk, how to assess that risk, and what to do if you learn your patient is in danger of committing suicide.

Suicide in patients with cancer: identifying the risk factors

We summarize the key points here.

Who is at risk?

Older age, chronic illness, multiple losses, and other reasons for suffering will intensify thoughts of suicide for people with cancer. Suicide in people with cancer most often occurs in these groups:

  • Elderly age, especially older white unmarried men
  • People with cancers of the head and neck, lung, pancreatic and stomach cancer, due to the morbidity of these cancers and their treatment
  • People with depression, hopelessness, demoralization, pain, lack of social support, feeling like a burden to others, a strong need for control, or existential concerns

Suicidal thinking

Suicidal thinking includes a spectrum from desire for hastened death (DHD) to actual suicidal ideation. DHD is “longing for death to occur more rapidly than it otherwise would.”30McFarland DC, Walsh L, Napolitano S, Morita J, Jaiswal R. Suicide in patients with cancer: identifying the risk factors. Oncology (Williston Park). 2019 Jun 19;33(6):221-6. Suicidal ideation (SI) “ . . . often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide.”31Harmer B, Lee S, Duong TVH, Saadabadi A. Suicidal Ideation. 2021 Aug 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.

Though suicidal ideation and history of suicidal behavior “are among the most salient short- and long-term risk factors for suicide,” a person can act impulsively without warning. It’s not unusual for a person with a chronic illness with significant morbidity to contemplate death and even suicide with thoughts such as “Maybe X would be better off without me.” These thoughts are related to a life adjustment and should be transient and not overtly bothersome or persistent. When these thoughts become ruminative or persistent, patients feel unsafe and may run a greater risk of attempting suicide. 

MacFarland et al. explain, “Even at this point, few patients are truly sure of their decision and will often reach out through subtle gestures. These patients can be helped greatly by an astute clinician who notices changes in cognition, emotion, and personality.”32McFarland DC, Walsh L, Napolitano S, Morita J, Jaiswal R. Suicide in patients with cancer: identifying the risk factors. Oncology (Williston Park). 2019 Jun 19;33(6):221-6. 

A desire to hasten death usually increases as a person gets closer to death. People wish for death to come swiftly for many common reasons including feeling depressed, hopeless, like a burden to others, losing independence, and fearing pain and suffering.

Assessment and intervention

The oncologist and other members of the oncology team who see a patient regularly can play an important role in identifying patients who are at high risk for suicide and supporting them. Since thinking about suicide is the patient’s way of wrestling with the will to live or to die, whatever can be done to “reduce suffering, restore connectedness, and maintain safety defuses suicidal thinking.“33McFarland DC, Walsh L, Napolitano S, Morita J, Jaiswal R. Suicide in patients with cancer: identifying the risk factors. Oncology (Williston Park). 2019 Jun 19;33(6):221-6. 

Being able to assess suicide risk is an important skill for members of the oncology team. A basic risk assessment can be done by those who are not mental health professionals. 

The oncologist and other members of the oncology team often are first responders to the psychological suffering of their patients. MacFarland et al. explain that a strong positive relationship between the patient and the oncologist can be protective against suicide; their recommendations:34McFarland DC, Walsh L, Napolitano S, Morita J, Jaiswal R. Suicide in patients with cancer: identifying the risk factors. Oncology (Williston Park). 2019 Jun 19;33(6):221-6. 

  • Active listening, concern for patients’ well-being, openness, and providing clear explanations
  • Communication skills training to improve oncologist–patient communication
  • Normalizing conversations about suicide in order to get appropriate resources to the right patients. Asking and talking about suicide can prevent it even when done by non-professionals

Additionally, your oncology practice needs  to have a valid suicide risk assessment tool available. You will also need a list of mental health professionals and a plan for referring patients to these professionals, preferably those with whom you have developed a triage and referral plan. 

Assessment tools

Several assessment tools are available. MacFarland et al. consider the Columbia-Suicide Severity Rating Scale (C-SSRS) to be a valid and reliable suicide assessment tool. They list other tools as well. Any score other than “0” (considered a non-zero intent to die) should categorize the intent to die as suicidal ideation and trigger intervention, including referral to a mental health professional.

Two other commonly used tools to assess desire for hastened death (DHD):

Schedule of Attitudes toward Hastened Death › 

Desire for Death Rating Scale ›

MacFarland et al. explain that since DHD is so closely associated with depression, a good approach would include addressing underlying depression. DHD may respond to psychological support even over other forms of comfort care.35McFarland DC, Walsh L, Napolitano S, Morita J, Jaiswal R. Suicide in patients with cancer: identifying the risk factors. Oncology (Williston Park). 2019 Jun 19;33(6):221-6. 

You may have had one or more patients ask you to hasten their deaths. These requests can often lead to psychological and moral distress in health care professionals. You may need to  examine and reckon with the thoughts and feelings this triggers in you. This reflection and reckoning will help you respond from a place of non-assuming, active listening, and discernment of what the person is asking you to do and what they need. Do they need more aggressive symptom management? Do they need reassurance that if they develop pain and other symptoms later, there are ways to control them and you will oversee this? Are they asking you to perhaps stop life-prolonging interventions such as chemotherapy or a ventilator? Do they want you to make sure they are allowed a natural death, even if that means not treating infection or not administering artificial nutrition and hydration? Or, perhaps they are talking about Medical Aid in Dying (MAID; formerly called Physician-assisted Suicide). 

The latter request may not be legally possible in your state or the one in which a patient resides. You may want no part in this, even if you are in a state with a death with dignity law. If a patient is indeed asking for MAID, exploring this option is important, whether you explore it with them or refer them to another professional who is skilled and knowledgeable in having these conversations. A palliative care or hospice physician, nurse or social worker may be a good resource in this respect. Some patients in MAID programs don’t go on to take the prescribed lethal dose of medicine.36Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act. 2020 Data Summary. February 26, 2021. Viewed March 21, 2022. The reasons for that are unclear, but some believe that good palliative/hospice care may lead some patients to not exercise their option to take the lethal medication.37Schencker L. Assisted-suicide debate focuses attention on palliative, hospice care. Modern Healthcare. May 16, 2015. Viewed March 21, 2022. Our experience in working with hundreds of cancer patients in the Cancer Help Program is that openly voicing fears about unbearable suffering and exploring options for avoiding, relieving, or ending that suffering is helpful.

When my patient does complete suicide

A completed suicide takes an emotional toll on everyone close to the person, including those on their oncology care team. We often are diligent in making sure the person’s loved ones receive “postvention” support. However, healthcare professionals need to be included in these interventions aimed at providing psychological care, destigmatizing suicide’s tragedy, making sense of the confusing aftermath, assisting with recovery, and providing support services to survivors who may now be at higher risk for suicide. Not only for the patient’s bereaved loved ones, but also for yourself and your staff, make sure that you offer options for mental health care.

Expert commentary

CancerChoices Senior Clinical Consultant Laura Pole, RN, MSN, Oncology Clinical Nurse Specialist: Clinicians should assess and treat other common problems in cancer that can cause or worsen depression, including pain, insomnia, hyperglycemia, dysbiosis, and altered stress chemistry.

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Authors

Laura Pole, RN, MSN, OCNS

Senior Clinical Consultant
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Laura Pole is senior clinical consultant for CancerChoices. Laura is an oncology clinical nurse specialist who has been providing integrative oncology clinical care, navigation, consultation, and education services for over 40 years. She is the co-creator and co-coordinator of the Integrative Oncology Navigation Training at Smith Center for Healing and the Arts in Washington, DC. Laura also manages the “Media Watch Cancer News That You Can Use” listserv for Smith Center/Commonweal. In her role as a palliative care educator and consultant, Laura has served as statewide Respecting Choices Faculty for the Virginia POST (Physician Orders for Scope of Treatment) Collaborative as well as provided statewide professional education on palliative and end-of-life care for the Virginia Association for Hospices and Palliative Care.

For CancerChoices, Laura curates content and research, networks with clinical and organizational partners, brings awareness and education of integrative oncology at professional and patient conferences and programs, and translates research into information relevant to the patient experience as well as clinical practice.

Laura sees her work with CancerChoices as a perfect alignment of all her passions, knowledge and skills in integrative oncology care. She is honored to serve you.

Laura Pole, RN, MSN, OCNS Senior Clinical Consultant

Nancy Hepp, MS

Lead Researcher and Program Manager
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Ms. Hepp is a researcher and communicator who has been writing and editing educational content on varied health topics for more than 20 years. She serves as lead researcher, program manager, and writer for CancerChoices. Her graduate work in research and cognitive psychology, her master’s degree in instructional design, and her certificate in web design have all guided her in writing and presenting information for a wide variety of audiences and uses. Nancy’s service as faculty development coordinator in the Department of Family Medicine at Wright State University also provided experience in medical research, plus insights into medical education and medical care from the professional’s perspective.

Nancy Hepp, MS Lead Researcher and Program Manager

Maria Williams

Research and Communications Consultant
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Maria Williams is a research and communications consultant who brings over 15 years’ experience in research, consumer education, and science communication to CancerChoices. She has worked primarily in public health and environmental health.

Maria Williams Research and Communications Consultant

Last update: July 6, 2022

CancerChoices provides information about integrative in cancer care, a patient-centered approach combining the best of conventional care, self care and evidence-informed complementary care in an integrated plan cancer care. We review complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocial therapy, and acupuncture therapies and self-care lifestyle actions and behaviors that may impact cancer outcomes; examples include eating health-promoting foods, limiting alcohol, increasing physical activity, and managing stress practices to help patients and professionals explore and integrate the best combination of conventionalthe cancer care offered by conventionally trained physicians and most hospitals; examples are chemotherapy, surgery, and radiotherapy and complementary therapies and practices for each person.

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