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Vol 1 | Issue 3 | Oct - Dec 2022                                                                                       Indian J Pharm Drug Studies | 79  

Review Article 

Depression among cancer survivors – An untold story  

Janice Jacson Mandumpala 

From, Department of Pharmacy Practice, Nirmala College of Pharmacy, Kerala, India  

Correspondence to: Janice Jacson Mandumpala, Pharm D intern, Department of Pharmacy Practice, Nirmala College of Pharmacy, 

Muvattupuzha, Ernakulam, Kerala, India. Email: janice.jacson@gmail.com  

ABSTRACT 

Mental health is an important area in the treatment of patients. Cancer not only burdens the individual during the treatment phase but 

also during the survivorship period. Multi-morbidities, being female, pre-existing psychological illness are few among risk factors that 

intensify the course of depression among cancer survivors. Depression can seep in through various means from the effects of treatment 

to accepting the reality of survivorship and it may vary depending on the type of cancer. Screening and as sessing for depression, patient 

self-management strategies, internet based mindfulness therapy and psychoeducational interventions are few among the possible ways 

to tackle the threat of depression in cancer survivors. This review summarizes the causes of depression, depression among various 

cancer types [thyroid, prostate, breast and rectal/ colorectal cancer] and applications of evidence to practice to overcome depression in 

cancer survivors. 

Key words: Depression, cancer survivors, breast cancer, prostate cancer, thyroid cancer, rectal cancer 

he psychological impact of diseases is an important 

aspect of the clinical cure of patients. “Mental illness is 

like any other medical illness” is an undeniable truth and 

necessitates immediate action in the healthcare sector [1]. 

Psychological problems are persistent among cancer patients, 

depression and anxiety being very common. This can make the 

treatment more challenging with additional difficulty in the 

management and cure of cancer. Depressive symptomatology is 

evident during the advanced stages of the disease and in the 

inpatient settings [2]. Studies have elaborated on the need for 

developing a management strategy to address the increasing 

burden of depression symptomatology among cancer patient [3].   

The psychological impact of diseases is an important aspect 

of the clinical cure of patients. “Mental illness is like any other 

medical illness” is an undeniable truth and necessitates 

immediate action in the healthcare sector [1]. Psychological 

problems are persistent among cancer patients, depression and 

anxiety being very common. This can make the treatment more 

challenging with additional difficulty in the management and 

cure of cancer. Depressive symptomatology is evident during 

the advanced stages of the disease and in the inpatient settings 

[2]. Studies have elaborated on the need for developing a 

management strategy to address the increasing burden of 

depression symptomatology among cancer patients [3].   

Causes  

The psychological impact of diseases is an important aspect of 

the clinical cure of patients. “Mental illness is like any other  

medical illness” is an undeniable truth and necessitates 

immediate action in the healthcare sector [1]. Psychological 

problems are persistent among cancer patients, depression and 

anxiety being very common. This can make the treatment more 

challenging with additional difficulty in the management and 

cure of cancer. Depressive symptomatology is evident during 

the advanced stages of the disease and in the inpatient settings 

[2]. Studies have elaborated on the need for developing a 

management strategy to address the increasing burden of 

depression symptomatology among cancer patients [3]. 

A variety of factors can steer depression among cancer 

survivors which may or may not interact with one another. 

Individual characteristics such as age, gender, ethnicity, 

sexuality, religion, disability, co-morbid health conditions and 

marital or co-habitation status influence development of 

depression. Psychological distress, coping behaviour, 

hopelessness, denial, anger, fear, grief, resilience, concern for 

others, change in self-image are psychological response to 

diagnosis and in the journey thereafter that impacts a cancer 

patient’s mental health. Social and contextual factors that has an 

undeniable affect are educational level, employment status, 

healthcare system, social and family support and stressful life 

events such as loss of a loved one.   

Prior psychological behaviour is also another less enquired 

history for cancer patients and it includes preexisting psychiatric 

disorders, previous suicidal behaviour and prior coping 

behaviour. Finally, treatment related modalities have a huge 

impact on the current and future status of cancer patients. They 

T 



Mandumpala                                                                                                               Depression among cancer survivors  

Vol 1 | Issue 3 | Oct - Dec 2022                                                                                       Indian J Pharm Drug Studies | 80  

include long term complications associated with treatment such 

as development of infertility and secondary cancers that can 

have adverse mental effects [7].  

Multiple comorbidities among cancer survivors also can 

influence their treatment outcomes and further research can 

prevent the development of adverse events due to comorbid 

conditions in these patients [8]. Screening for depression is 

crucial in the web of multi-morbidities. Approaches for 

managing multi-morbidities should also include effective ways 

to tackle the impending threat of depression [9].   

Depression among Various Types of Cancer Survivors  

Thyroid cancer  

Multiple comorbidities among cancer survivors also can 

influence their treatment outcomes and further research can 

prevent the development of adverse events due to comorbid 

conditions in these patients [8]. Screening for depression is 

crucial in the web of multi-morbidities. Approaches for 

managing multi-morbidities should also include effective ways 

to tackle the impending threat of depression [9].   

Prostate cancer  

Prostate cancer is the second most prevalent cancer after lung 

cancer among men. Treatments tailored include radical 

prostatectomy, radiotherapy, observational or watchful waiting 

and chemotherapy. They pose adverse risk of side effects such 

as incontinence of urine, bowel problems, erectile dysfunction, 

pain, insomnia and fatigue that persists for a long time. 

Gynecomastia and hot flashes are the two prominent side effects 

of androgen deprivation therapy. They are associated with 

shame, loss of masculinity, stigma and followed by 

psychological distress. Urine incontinence may trigger fear of 

smelling, leakage of urine and an embarrassment to use 

incontinence pads, together culminating in social isolation with 

aggravated depressive symptoms [12]. Physical side effects are 

positively associated with sleep disturbances and increases the 

burden of cancer-related fatigue. Thus, the pleiades of 

consequences post treatment among cancer survivors can pose 

a significant risk for depression in this cohort [13].  

Lack of food security, racial discrimination, housing 

instability and other consequent effects of racial differences can 

elevate the incidence of depression among prostate cancer 

survivors belonging to specific communities. Racial disparities 

can have an impending burden on the existing situation of a 

prostate cancer survivor. In a study conducted by Parikh et al, it 

has been concluded that incident depression is common among 

African American cohort of prostate cancer survivors in 

comparison to the Whites [14]. Although evidence is nascent, 

future studies, should examine the impact of race on the 

development of depression among cancer survivors.   

Breast cancer  

Breast cancer is the most prevalent cancers in the world. 

Emotional distress among breast cancer patients can reduce 

their medication adherence, and lead to poor quality of life and 

intense fear of their disease. Breast cancer patients often 

experience a spectrum of depressive symptomatology [15]. The 

prevalence of depression among breast cancer survivors ranges 

from 13% to 45% [16]. Breast cancer survivors include those 

who have received treatment and are on long term follow up to 

reduce the recurrence of cancer and to improve the quality of 

life [17].   

Breast cancer survivors are much-ignored section of the 

population who are at an increased risk of developing depression 

in comparison to breast cancer patients. They experience a 

multitude of symptoms such as impaired sleep, fatigue, 

arthralgia, stress, impaired sleep, hot flashes, vaginal dryness, 

decreased sexual interest, problems during urination, weight 

gain, anxiety and depression. There is an impending need to 

address these issues and timely deliver interventions to help 

them [18].    

Screening for depressive symptoms is needed but without 

assessing the need for intervention, the practicality of the issue 

remains unmet. Shreds of evidence reflect a greater incidence of 

depression among the early survivors [within 5 years of 

treatment] than late survivors [within 10 years of treatment]. 

The preceding group of survivors tend to experience depression 

due to fear of recurrence and treatment related side effects [19].   

A recent study conducted among the black breast cancer 

survivors reiterates the need for a good patient-provider 

relationship and patient empowerment as the key components to 

develop during the breast cancer survivorship program. 

Incidence of depression can be largely decreased among the 

black breast cancer survivors with the incorporation of special 

patient-centered communication [20].   

Rectal/ colorectal cancer  

The different types of surgery instituted for rectal cancer are 

permanent ostomy, temporary ostomy followed by anastomosis 

and initial anastomosis. A study has found that the prevalence 

of depression among rectal cancer survivors to be 24.7% among 

long term survivors and more prevalent among long term 

survivors who have undergone permanent ostomy. As per the 

findings of the study conducted by Chongpison et al. females 

face greater burden of depression when undergoing permanent 

ostomy in comparison to anastomosis [21].   

Colorectal cancer survivors also develop persisting 

symptoms of depression, approximately 1 in 5 survivors post 

treatment. Risk factors such as multi-morbidities, being single 

or divorced, lower educational status and high disease stage can 

contribute to the genesis of depression in this vulnerable cohort. 

Hence, it is vital to know whether the survivors need 

psychological help to reduce their depressive symptoms [22].   



Mandumpala                                                                                                               Depression among cancer survivors  

Vol 1 | Issue 3 | Oct - Dec 2022                                                                                       Indian J Pharm Drug Studies | 81  

Application  of  Evidence  in  Clinical Practice  

Patient reported outcomes is the corner stone of cancer 

survivorship. Therefore, it is necessary to also assess the 

symptoms associated with mental health among cancer 

survivors during their routine health check-up. Screening and 

assessing for depression in the oncology setting can improve 

and help achieve better patient outcomes [23]. The screening 

will help detect patients who have a major depressive disorder 

but are not undergoing any treatment or patients in whom 

depression is not recognized [24]. 

Certain cancer treatments are prone to induce neurotoxicity and 

this aspect should be considered while screening for psychiatric 

conditions. Certain symptoms that are associated with poor 

outcomes and examples include pain and anxiety among 

depressed patients. Targeting these symptoms can be an 

inestimable strategy to cope with depression. It is also necessary 

to engage in depth interviews that can extract the exact 

symptoms that are known to interfere with the function and 

quality of life. Fatigue, hopelessness, worthlessness, negative 

self-image and helplessness are a few of them. Hence, the 

importance of identifying the symptoms and their associated 

burden on the patients cannot be neglected and should be 

incorporated during the screening and counselling process [6].  

It is necessary to raise awareness across various strata of the 

healthcare system about mental health symptoms during cancer 

survivorship.   

Patient preferences are another unexplored area when 

considering screening for depression. Evidence suggests that 

cancer patients prefer screening services during follow up 

through face to face interviews at regular intervals with a nurse 

within their cancer services. The patient perspective remains an 

unquestionable area of importance, as patient centered care is 

the aim of medical care [25]. Oncology health professionals are 

better suited for screening and can initiate the process of 

screening than wait for any adverse event from occurring. 

Routine screening can be applied for depression screening in 

cancer patients and among survivors, than selectively providing 

psycho-oncology services [26].  

The patient when visiting the primary health care centres can 

seek self-management techniques. Good eating habits, engaging 

in daily exercise and hygienic sleeping practices are few to 

follow. Patients are also encouraged to engage in community 

reconnection, make interpersonal changes and function 

optimally [27]. Evidence suggests incorporation of physical 

activity as a part of daily routine to prevent developing 

depression among cancer survivors.  

Participating in physical activity and meeting weekly goals 

of exercise duration and intensity, is a low cost, 

nonpharmacological intervention that can reduce the severity 

and incidence of depression during cancer survivorship [28]. As 

per Consensus statements from an International 

Multidisciplinary roundtable meeting, it is concluded that 

cancer survivors should participate in exercise training, improve 

their physical fitness and restore their normal functioning which 

can help them mitigate the overwhelming effects of depression 

post-treatment. Aerobic training, aerobic plus resistance training 

and resistance training alone in specific doses can prevent the 

advent of depression among cancer survivors [29].   

It is advocated that every survivor develops a ‘culture of 

wellness’ and proactively works to maintain a healthy mental 

state. Internet based mindfulness therapy is another novel and 

patient friendly approach practiced actively in the developed 

nations. This is a particularly useful technique among the breast 

and prostate cancer cohort as they have documented long term 

survival. This method not only addresses the acute symptom 

care but also teaches skills that can help patients prevent 

symptom aggravation and reversal. Old age is a significant 

barrier to internet based therapy attributed to their inadequate 

knowledge about internet and lack of motivation. Internet based 

therapy is useful for individuals as they can participate from 

their homes. This is a promising method for patients who do not 

seek special psychological treatment [30]. Online mindfulness 

therapy can be employed for various groups of patients such as 

those in whom mindfulness skills will be difficult to reach out 

traditionally and for those who are on waitlist for face to face 

interview [31]. Endorsement of such techniques through the 

clinician or healthcare professionals can drive patient uptake 

and engagement [32]. Although internet based mindfulness 

therapy is in its infancy, in the context of public health it is an 

emerging strategy to alleviate depressive symptomatology and 

reduce the prevalence of depression among cancer survivors.  

Clinical trials have shed light on the novel methods that can 

be incorporated in healthcare practice for managing depression 

among cancer survivors. A study conducted in Quebec and 

Ontario has discussed about the usefulness of telephone-

delivered depression self-care intervention for cancer survivors. 

As per the findings of their study CanDirect, a telephone-

delivered intervention produced greater reduction in depressive 

symptoms and greater quality of life. Thus, instilling hope in 

newer directions such as CanDirect can satisfy the unmet needs 

of cancer survivors in the society [33].   

Evidence also suggests the role of a nurse-delivered 

intervention in addition to the usual care that can substantially 

improve the clinical outcomes in patients with cancer. Nurse-

delivered interventions include education about depression, 

conducting a problem-solving session to develop a positive 

attitude among patients while dealing with testing situations, 

helping them communicate their concerns to the clinicians and 

also gaining the cooperation of clinicians [34]. Nursing 

interventions targeted to alleviate depression among breast 

cancer survivors should accommodate the psychological needs 

of the patient and their care takers [35].  



Mandumpala                                                                                                               Depression among cancer survivors  

Vol 1 | Issue 3 | Oct - Dec 2022                                                                                       Indian J Pharm Drug Studies | 82  

Screening for depression can be implemented through the 

PHQ-2 item questionnaire, further diagnosis can be established 

where screening results necessitate treatment initiation. 

Although the rate of false positive detection for depression 

remains high, nurse based interviews and screening should be 

considered. It should be conducted to improve symptoms and 

prevent relapse, rather than increasing the duration or burden of 

treatment [36]. Inculcating a strong evidence based practice 

from the point of care itself can be the genesis of improved 

mental health among cancer survivors.   

There is an unmet need for psycho-educational interventions 

among cancer survivors which needs to be addressed. 

Psychological needs have been categorized as one of the eight 

unmet needs in a cancer patient’/survivor’ journey, especially 

among breast cancer survivors. Studies from the United States 

highlight a higher preference among patients for individual 

professional counselling over received pharmacological 

treatment for depression. Psychiatric medications are least 

preferred and are only desired by patients when diagnosed with 

depression. Therefore, it can be understood that psycho-

educational counselling is well recognized by the patients and 

can be readily adopted within the cancer care setting [37].   

CONCLUSION  

Depression is a leading cause of concern in the healthcare sector. 

The scientific community has addressed the importance of 

identifying major depressive disorder among cancer patients. 

There is still a lack of strong evidence and very less attention is 

paid to the mental health vulnerabilities faced by cancer 

survivors. It is more pronounced among females who carry a 

higher risk for mental health diseases. From the given review, it 

is understood that individuals diagnosed with cancer undergo 

varying levels of trauma during their treatment. Not only are the 

treatment effects a causative factor for the development of 

depression, but the future concerns associated with cancer cure 

are equally contributory. Cancer itself and a cure from it pose 

the risk of depression, but the situation is even grim when the 

needs of a survivor remains unaddressed. Future studies are 

warranted to assess the prevalence of depression across various 

cohorts. Such scientific and epidemiological shreds of evidence 

can help tailor the right strategies for addressing health concerns 

prevalent in society.   

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Mandumpala                                                                                                               Depression among cancer survivors  

Vol 1 | Issue 3 | Oct - Dec 2022                                                                                       Indian J Pharm Drug Studies | 83  

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How to cite this article: Janice Jacson Mandumpala.  

Depression among cancer survivors – An untold story. 

Indian J Pharm Drug Studies. 2022: 1(3) 79-83. 

Funding: None             Conflict of Interest: None Stated 

 


