Breast Cancer and Depression: Known Link, Understudied Treatments

Each year more than 280,000 women in the United States learn they have breast cancer, a diagnosis that can trigger severe emotional distress, including depression.

Studies show that up to a third of breast cancer patients experience symptoms of depression both during and after treatment. Despite this well studied link between breast cancer and depression, determining the most effective treatments for addressing this combination has been understudied.

Columbia psychiatrists John Markowitz, MD, professor of clinical psychiatry, and David Hellerstein, MD, professor of clinical psychiatry and director of the Depression Evaluation Service, in collaboration with Dawn Hershman, MD, of the Herbert Irving Comprehensive Cancer Care Center at Columbia, are co-leading a study to find out which treatments work best to alleviate major depressive disorder and improve the quality of life in individuals with breast cancer.

Columbia Psychiatry spoke with Dr. Markowitz about prevalence of co-occurring conditions, treatments, and the Columbia breast-cancer depression study.

How common is depression among patients who have breast cancer?

It’s unfortunately all too common. Distressing major life events can trigger major depressive episodes in individuals who are vulnerable to getting depressed, and learning you have breast cancer is a major life event. A range of research studies have shown that individuals with breast cancer have a three times greater risk of developing depression than those without breast cancer. Each condition worsens the course of the other.

Isn’t depression just a normal reaction to breast cancer?

No, it’s not. While it’s understandable to be worried, sad, and upset when finding out you have cancer, a major depressive episode goes well beyond feeling anxious or sad. Clinical depression is debilitating. It interferes with life and can prevent people from getting optimal treatment for the cancer. Depression leads to social withdrawal; low energy; disturbed sleep and appetite; feeling helpless, hopeless, and guilty; and even giving up on life.

Do antidepressant treatments work for people who have both depression and breast cancer?  

Despite the frequent co-occurrence of depression with breast cancer, surprisingly little research has sought to answer this treatment question. In general, we know that the same treatments seem to work for depression with breast cancer as for depression in the general population without cancer. Prescribing antidepressant medications like serotonin reuptake inhibitors and antidepressant psychotherapies are reasonable treatment approaches  Interpersonal psychotherapy (IPT), which aims improve the quality of a person’s relationships and social functioning to help reduce their distress, and cognitive behavioral therapy (CBT), which teaches patients how to identify and change the destructive or disturbing thought patterns that have a negative influence on their behavior and emotions, can both be helpful.

Which works better for depression, medication or psychotherapy?

No single treatment works for everyone, but the proven treatments work for most people most of the time. Antidepressant medication and psychotherapy have each been shown to help patients with depression and breast cancer, but surprisingly, the two treatment types have never been directly compared. To answer the question of which might work better and for which sorts of people, we are doing the first such study now at Columbia/New York State Psychiatric Institute, comparing 12 weeks of tele-therapy with a serotonin reuptake inhibitor (venlafaxine or escitalopram) to interpersonal psychotherapy.

If there’s little research, how do I decide on a treatment?

Research studies comparing the two approaches would greatly expand our understanding of what works better for whom. Lacking that, we know some general factors that predict treatment outcomes. One is that it helps to get the treatment that you want. Some people with depression would rather work in psychotherapy to figure out issues in their lives. Resolving those issues makes their lives and their moods better. Others would rather not to talk, preferring to take a pill that makes them feel better. Medication tends to work faster than talk therapy and may have advantages for symptoms patients with breast cancer may be experiencing, such as physical pain. Psychotherapy, on the other hand, helps people rethink their attitudes and lives. A third option is to get both antidepressant medication and psychotherapy.    

And what about side effects?

Every treatment can have side effects: every pill (starting with aspirin) and every psychotherapy. The U.S. Food and Drug Administration approves treatments only if their benefits considerably outweigh their side effects. Serotonin reuptake inhibitor antidepressants can have a variety of side effects, though they are mostly mild. They usually arrive in the first day or so and can include jitteriness, drowsiness, headache, and stomach upset, but usually subside fairly quickly. Other side effects, like weight gain or loss of sexual interest or arousal, can be ongoing. Side effects, however, aren’t permanent and disappear when a patient discontinues the medication; however, some of these medications can have an uncomfortable withdrawal if they are stopped too quickly. There is a possibility of antidepressant medications interacting with tamoxifen and other cancer treatments, although choosing venlafaxine or escitalopram from among the available antidepressants minimizes that risk. Psychotherapies can raise uncomfortable feelings and sensitive topics. They also take more time than medication. And while medication comes in standard measures (you know how many milligrams of medicine are in a pill, for example), not all psychotherapists are equal. Two different therapists conducting the same therapy can do so with differing degrees of expertise.

Do you have breast cancer, and are you struggling with depression? Columbia Psychiatry is offering individuals who have non-metastatic breast cancer and depression 12 weeks of either tele-psychotherapy or tele-antidepressant medication with a serotonin reuptake inhibitor. Treatment is randomly assigned (by "a coin flip") and at no cost. All sessions will be held by Zoom. Head here for more information about the study.