March 2003: Overcoming Depression

Identifiying normal anxiety, fear, and depression?

Question from Jemima B: How can I tell the difference between normal anxiety and fear around breast cancer and what would be defined as depression that warrants professional help?

Answers —Rosalind Kleban, L.C.S.W.: There is a great deal of normal anxiety and depression surrounding a diagnosis of breast cancer. The anxiety and/or depression that is worrisome, and that warrants outside help, is the kind that interferes with a person's daily life. If a person can't continue having dinner with her family, or can't interact normally with friends and family, or go to a movie even if she feels well enough physically, or is unable to sleep or sleeps all day, that signals depression. If any of these extreme disturbances go on for a long period of time, I think it's important to speak to a physician about what could be done to help deal with this.

Diane Thompson, M.D.: I agree. When we think of depression we often ask patients about changes in appetite and energy. However, a patient going through chemotherapy may already have problems with appetite and energy. One of the most important things we look for is a change in a patient's ability to enjoy herself. There's a word we often use—the term is "anhedonia." This means lack of pleasure. It's important to let your doctor know if you are not experiencing pleasure in things that you normally enjoy.

Jennifer Griggs, M.D., M.P.H.: It's important to find somebody on your healthcare team to speak to about your feelings. Your doctor, your nurse, your social worker—these are all people that you can talk to. You can get a sense from them about whether what you're feeling is normal, or signals real depression.

Can depression spread to family?

Question from Gothgrrl: Can family members get depressed too? I'm so scared for my mom, and I don't know what to do.

Answers —Rosalind Kleban, L.C.S.W.: Family members can become depressed over the situation. However, the effect is usually much greater on the patient. And families are a lot stronger than we give them credit for. Patients often worry about their mothers, and how difficult it can be for them to deal with this situation. However, I have found that mothers of all ages are able to cope with the situation and be very supportive of their daughters.

It's important to keep the lines of communication open. Keeping secrets in order to protect family members is often burdensome for the patient and creates more stress and even lack of trust with the family. An open dialogue that permits everybody to have feelings is generally more helpful. Also, family members tend to recover more quickly than patients. When treatment is over, patients often have emotional issues for a year to a year and a half afterwards. It's been my experience that the families recover almost immediately.

Diane Thompson, M.D.: One of the things I worry about is that patients sometimes keep secrets or end up acting like "cheerleaders" for their families. Sometimes being overly cheerful and "cheerleading" can be exhausting, and the family would really prefer to help the patient. Family members often feel helpless, but patients can make them feel better by allowing them to be involved and to help. For example, doing laundry or cooking meals can be important ways for family members to help the patient and help her family as they deal with the cancer.

Jennifer Griggs, M.D., M.P.H.: A family that has had difficulty coping with stressful situations in the past may find it especially difficult to cope with a breast cancer diagnosis. Working with your doctors and your social worker in the early stages of diagnosis and treatment can help address some of the patterns that families fall into. Doctors often like to treat the whole person, and the whole person comes along with her family. You don't need to be alone in speaking with your mom or other family members about your diagnosis and treatment.

Rosalind Kleban, L.C.S.W.: Including family members in the treatment process is often helpful. We frequently encourage patients to bring family members, including children, to the treatment center so they can feel comfortable about the surroundings in which their relative is being treated. I also think family members feel more comfortable when they know the physician who is taking care of their relative. It has certainly made many of the children feel better about what is happening in the home.

Jennifer Griggs, M.D., M.P.H.: It takes away the mystery.

Rosalind Kleban, L.C.S.W.: What children imagine is always worse than the truth.

Side effects of St. John's Wort?

Question from Milly: I have been told that the herb St. John's Wort can help ease depression. Does this herb have side effects?

Answers —Diane Thompson, M.D.: There is very little information about the use of St. John's Wort in cancer patients. I have specific concerns about possible interactions between St. John's Wort and other medications. St. John's Wort can affect how other medications are broken down in the liver. As far as specific side effects go, there aren't many notable side effects. Some patients complain of nausea. I would encourage anyone who is thinking about St. John's Wort to talk to his or her physician and discuss other medications if they are interested in trying an antidepressant.

Jennifer Griggs, M.D., M.P.H.: A recent report focusing on patients with colon cancer showed that St. John's Wort "undid" the effectiveness of the chemotherapy drugs. Certainly, one would not want to go through chemotherapy and NOT experience the maximal benefit. While we don't have data that this kind of interference occurs with breast cancer chemotherapy, the lack of information is due to the fact that this issue hasn't yet been fully studied.

Yoga, meditation aid in depression?

Question from SueAnne: Do you think yoga and meditation would be good for depression sufferers?

Answers —Rosalind Kleban, L.C.S.W.: I think that when people are diagnosed and are having trouble with the diagnosis as we expect for most people, there are any number of interventions and activities that people can try. Certainly meditation, yoga, and relaxation are useful for many people. I do get concerned, however, when patients think they SHOULD do yoga or they SHOULD do meditation. In such cases, they may feel guilty that they're not using these therapies, or they try some of them and find that they're not helpful, and then feel somehow that they themselves have failed. If these activities are helpful and beneficial, that's wonderful. But there shouldn't be any pressure to either participate or feel that they HAVE to be helpful.

Diane Thompson, M.D.: I agree. The stress and anxiety that come with this diagnosis can be overwhelming, and it's natural to search for ways to help alleviate distress. I recommend doing what's worked in the past, but I also stress the importance of being GENTLE with oneself during diagnosis and treatment.

Is it fatigue or depression?

Question from Sylvia: I am so tired because of my treatments that I can't be bothered to do anything at all. My sister keeps saying I am depressed and that is why I feel the way I do. I never thought I'd have to deal with a mental illness in addition to the breast cancer. How can I find out for sure who is right?

Answers —Diane Thompson, M.D.: For many patients—up to 60 percent, in fact—depression can occur for the first time after a diagnosis of cancer. This is true of any cancer, from breast to prostate. Sixty percent is a big number, but that isn't everyone. If you are experiencing episodes of irritability, tearfulness, difficulty with sleep, appetite, energy or feelings of hopelessness, it is very important to discuss this with your doctor.

Rosalind Kleban, L.C.S.W.: In response to the previous question, Dr. Thompson urged patients to be gentle with themselves. In many cases it's really normal to feel depressed after being diagnosed with breast cancer. It needn't be looked upon as a mental illness, but as an expected response to a crisis. Part of taking care of oneself is to discuss it with the medical team, to get a better understanding of what's happened and what can be done about it.

Jennifer Griggs, M.D., M.P.H.: Even though breast cancer treatments can lead to overwhelming fatigue, there should be some "breaks" in that fatigue where you feel like you're starting to feel like yourself again before the next treatment. If you feel fatigued 100% of the time and it's interfering with your functioning, it's a serious problem and needs to be addressed.

There may be a medical cause for overwhelming fatigue; if you're not anemic, depression may be causing your fatigue. Bringing this to your doctor's attention is the best first step. I also recommend you let the doctor know what kinds of treatments you'd consider for depression. Some people tell me they think they're depressed, but they never tell me they don't want medication or that they're opposed to antidepressant medication. As a result, I think they're asking for an antidepressant. Don't hesitate to tell your doctor what you think should be done for your depression. You and your doctor are a team.

Taking antidepressants means weakness?

Question from Flavia: I thought only fragile people took antidepressants. My doctor wants me to try them, but I feel like I'm admitting I can't cope if I take them.

Answers —Diane Thompson, M.D.: Depression is a medical condition just like diabetes or hypertension (high blood pressure). If we take the parallel to hypertension, there are several ways to treat it. One is weight loss and exercise, but another treatment that may be important, because it will act quickly, is medication. This is also true of depression. There are treatments for depression, including talk therapy, that can be very effective, but medication can often alleviate symptoms faster. Depression is a medical condition, not a character flaw, and treating it can allow for a better overall quality of life.

Jennifer Griggs, M.D., M.P.H.: We have named depression after the mood component of the illness, but we could have called it something else—something implying the difficulty with sleep or concentration. I think if we think of depression as a neurological problem rather than a weakness, accepting treatment may be more palatable. Diane, have you found that?

Diane Thompson, M.D.: Yes. The other point is that chemotherapy and radiation have both been associated with depression. Therefore, while we can't change that fact, we can do something to address the component that may be due, in part, to the treatment.

Jennifer Griggs, M.D., M.P.H.: Good point!

Rosalind Kleban, L.C.S.W.: All too often I see patients who view depression as a character flaw and a weakness. But that's a case of blaming the victim. And it often doesn't allow the patient to get the remedy that would be so helpful. We accept medication for so many illnesses—neurological illnesses, chemical imbalances—that it would be helpful to see depression as an illness like the others, and in most cases a normal, even expected response to a diagnosis of breast cancer.

How long does depressioon last?

Question from Ashleigh: Am I going to feel depressed forever? I just can't see any light at the end of the tunnel right now.

Answer —Rosalind Kleban, L.C.S.W.: When you're in the middle of treatment, or at the beginning of the post-treatment period, it can be impossible to see light at the end of the tunnel. When I do support groups, I always include a volunteer who was treated many years ago. Our present volunteer was treated 10 years ago, and she's a sterling example to patients that feelings of depression, fear, and vulnerability do end. No one can give an exact date, and it doesn't happen all at once. But at some point, life returns to normal. Some patients even feel that, given their experience when they get to the other side, they have a greater appreciation of life.

Can tamoxifen increase depression?

Question from Rachel: Can tamoxifen increase a tendency toward depression? I am 5 months post-mastectomy with an excellent prognosis. I had been feeling centered throughout the past months but now, in the past few weeks, I am feeling increasingly depressed.

Answers —Diane Thompson, M.D.: Although we don't have scientific proof of this, I've heard many patients say that they were feeling fine until they started tamoxifen, or that they started feeling much less depressed after stopping tamoxifen. However, I would NOT encourage anyone to stop his or her tamoxifen for this reason. I would encourage anyone who feels that his or her depression has worsened or started after the tamoxifen to talk to his or her physician. In many cases, I have used an antidepressant in combination with tamoxifen, and patients have improved dramatically and continued on the tamoxifen for its usual duration.

Jennifer Griggs, M.D., M.P.H.: In the prevention study with tamoxifen vs. placebo (sugar pill) there was no increased risk for depression in women on tamoxifen. The result of this study is that most medical oncologists, including myself, tell women that it is probably not tamoxifen alone that is causing the depression. Instead, depression is probably due to a number of things, including the cancer diagnosis, chemotherapy, negative changes in one's self image, and hormonal changes.

Are antidepressants addictive?

Question from Linda G: Are antidepressants addictive? I read that a group of women in California had the labeling of Paxil changed because that drug IS addictive. Is that true?

Answer —Diane Thompson, M.D.: Some people notice what we refer to as a 'discontinuation syndrome' when they stop taking certain antidepressant medications. This seems to occur more often with some antidepressants than with others. Paxil (chemical name: paroxetine) has been noted to produce a discontinuation syndrome that feels much like the flu when the medication is stopped abruptly. This doesn't happen to everyone, but for those who experience it, it can be quite uncomfortable. If someone is taking Paxil, I encourage her to discuss tapering this medication when she and her doctor decide it is time to stop treatment. However, Paxil is NOT addictive.

Editor's Note: If you are taking tamoxifen, talk to your doctor about which antidepressants are safe for you to take. Some antidepressants -- including Paxil, Wellbutrin (chemical name: bupropion), Prozac (chemical name: fluoxetine), Cymbalta (chemical name: duloxetine), and Zoloft (chemical name: sertraline) -- interfere with the body's ability to convert tamoxifen into its active form, preventing you from getting the full benefit of tamoxifen. For more information, please visit the Tamoxifen page.

Can change of diet help ease depression?

Question from Dennie: Could a change of diet help ease depression? Are there any particular foods that can help alleviate it?

Answers —Diane Thompson, M.D.: Eating a healthful diet is so important, particularly while undergoing breast cancer treatment, although it can be hard to eat well during that time. There is no magical diet, but it is important to consume a diet that is as balanced as possible.

Jennifer Griggs, M.D., M.P.H.: One thing to avoid if you're depressed is alcohol. If you find that you're drinking more alcohol than you used to, this is something to discuss with your treatment team.

Rosalind Kleban, L.C.S.W.: Eating has always been seen as a way of nurturing oneself and giving oneself a treat, and during treatment women often try to cheer themselves up by overeating. I often tell patients that if a moderate gain of 10 to 15 lbs. is not going to be disturbing, perhaps they can give themselves that treat. If, however, that weight gain is going to add to the depression, then the patient is going to have to be more thoughtful about the eating and perhaps when the urge strikes, indulge in carrots and celery instead of cookies.

Diane Thompson, M.D.: While a healthy diet is important, we know more about ways that exercise can improve mood. Exercise can definitely improve mood, and, in fact, increases some of the neurotransmitters associated with mood. When we exercise, levels of serotonin and norepinephrine rise. An increase in these substances is associated with improved mood. This doesn't mean patients should start training for a marathon, but rather do what's comfortable for them. Doing things like taking a walk can increase those mood-elevating substances.

Geodon attributed to breast cancer?

Question from Emmy: I took Geodon, an antipsychotic, for the past year and a half. Is it possible that I got locally advanced breast cancer from taking Geodon?

Answers —Diane Thompson, M.D.: It is very unlikely. There are no studies that support a direct relationship between this antipsychotic and breast cancer.

Rosalind Kleban, L.C.S.W.: So many of the questions we're hearing tonight are really addressing the issue of "What have I done? What is my contribution to the diagnosis of breast cancer?" Experiencing a diagnosis of breast cancer and undergoing treatment is very difficult and rigorous. To add guilt just makes the experience more difficult and painful. There's much that we don't know about why people get breast cancer. What we DO know is that it's not caused by a woman's character or lifestyle. The need to search for a reason helps us feel in control; however, self-blame is both painful and untrue.

Suggestions for loss of appetite?

Question from Jo: I have lost my appetite and literally have to force myself to eat once a day. Should I be taking a tonic to increase my appetite?

Answers —Diane Thompson, M.D.: Appetite loss certainly can occur during treatment. As a psychiatrist, when someone tells me about appetite loss, I often think of depression. However, this is just one of the causes of appetite loss. This is an important topic to discuss with your physician as there are medications that can help with appetite. During a discussion, you and your doctor can pick the one that would be most appropriate for you.

Jennifer Griggs, M.D., M.P.H.: If your appetite returns before you receive your next treatment, you may need to have better control of nausea with your chemotherapy. But if this is a longstanding or chronic problem, it is most likely not due to the chemotherapy itself but may be due either to the cancer or to other factors, such as depression.

Preventing depression during treatment?

Question from Susan: What are some things we can do to prevent depression from developing during treatment?

Answers —Rosalind Kleban, L.C.S.W.: Depression, sadness, fear, and anxiety are really normal responses to a diagnosis of breast cancer. There is nothing that any of us fears more than a diagnosis of cancer, and having these responses is neither good nor bad, but normal. The attempt to push these feelings away, to deny them, takes more energy than it's worth. And if chemotherapy continues, it takes more energy than the patient has.

Women need to experience the feelings, go through them, look for techniques that are helpful, such as exercise, yoga, meditation, and support groups or counseling. With time, all these uncomfortable feelings will ease up, but unfortunately there's no magic way of going through what is really a normal response.

Diane Thompson, M.D.: While depression may not happen to everyone, it's important to know that it is very common. While we cannot protect ourselves from feeling depressed, we can understand that it happens and let our families know how we feel. If we can discuss symptoms of depression with a spouse or family member, then the whole "team" can have a better understanding of depression if it occurs, as well as urging family members to get treatment if necessary.

Jennifer Griggs, M.D., M.P.H.: Avoiding isolation and staying involved in activities that nurture you can be good ways to lessen depression. You may find that your friends and family keep asking "How are you?" In being concerned about you, they may forget your shared jokes, interests, and the activities that represent the real you. Staying connected through things that are important to you, whether it be work, friends, or hobbies, is important. This will help you avoid isolation. Although it may not prevent depression, it may lessen the severity of depressive symptoms.

Normal to have anxiety about leaving home?

Question from Carol: I have anxiety about leaving my house and going out. I am 6 months post treatment and getting more and more "homebound." Is this common, and is there something I can do to help me get back to "normal"?

Answers —Rosalind Kleban, L.C.S.W.: I have seen this happen quite often with patients at the Breast Center where I work. People come from all over the world to be treated at Memorial Sloan Kettering Cancer Center, and during treatment they talk about their eagerness to return home. However, when treatment is finished, they're often apprehensive about going so far away from their treatment center. Anxiety is often heightened when treatment is finished because you're no longer protected by medication and the constant attention of the medical staff. With time, this anxiety goes away. Life just intrudes, forces people to return to the life they had before, and that increased anxiety diminishes.

Diane Thompson, M.D.: I agree with Roz that this usually gets better with time, but not in every case. If you find that you are spending more and more time in your home, or experience panic or anxiety attacks when you leave home or try to leave, then it is very important to let your physician know about this. If this is disabling, there are certainly treatments that can be helpful. Both medication and/or talk therapy may be necessary.

Help for depressed husband?

Question from Summer: My husband is very down at the moment and I don't have the energy to pep him up because I am using all my energy to keep myself together. What could help him?

Answers —Rosalind Kleban, L.C.S.W.: I would encourage him to continue with the activities that have traditionally helped him—getting together with friends, or playing sports, for example. If these coping mechanisms are failing him right now, he needs to be encouraged to seek professional help. He could start by speaking to his wife's medical team to see what they have to suggest. I've just begun a spouse and partner group, and it's been a wonderful opportunity to give these men a safe place where they can share their feelings without worrying that they're burdening their wives or girlfriends. It's often helpful for a patient's spouse to just talk to the medical oncologist. It is too burdensome for the patient to be the "cheerleader" and keep the whole family afloat.

Jennifer Griggs, M.D., M.P.H.: Sometimes husbands feel very powerless, and it's not a comfortable feeling. If they can be told where to get information, they can feel that they are participating a little more. The website www.breastcancer.org is one place where husbands can get reliable, expert information about what's happening with their wives.

Diane Thompson, M.D.: I've talked with many women who don't understand why their husbands are so frustrated. I often talk to them about the wonderful ability their husband may have to fix things. If a man is used to fixing the sink when it leaks, for example, it can be very frustrating not to be able to "fix" the person he loves. Therefore, I really encourage husbands to look for the support that we've just talked about.

Increased stress due to continued biopsies?

Question from Terry: It seems that I continue to need biopsies, and each one causes me so much stress that I find myself just wanting it all to stop.

Answer —Rosalind Kleban, L.C.S.W.: That's a very difficult situation that many, many patients experience. Too often the route through breast cancer is not smooth, and people are often stopped by these additional tests, biopsies and waiting for results—which is probably the most tortuous time during a cancer experience. The things that can help are the things we've been discussing during this conference. We can go back to exercise, yoga, meditation and support groups, and sometimes medication.

After many years of frightening experiences, one patient told me she finally figured out how to get through tests. When I asked what that magic was, she said "Drugs." It's such an uncomfortable, miserable, anxiety-provoking situation that it's important to find some way to get through this more comfortably.

Lack of estrogen leads to mood changes?

Question from Lily: Does the sudden lack of estrogen after chemotherapy and taking medications like Arimidex or tamoxifen, have something to do with the mood changes and depression that women experience after breast cancer?

Answers —Diane Thompson, M.D.: It certainly is possible, because changes in estrogen can affect mood. Estrogen, like exercise, can have positive effects on serotonin and norepinephrine, those substances that are associated with mood. So a change in estrogen levels due to medication may indeed play a role in causing symptoms of depression.

Jennifer Griggs, M.D., M.P.H.: It always feels to me like we're adding insult to injury when we induce menopause with chemotherapy. If you let your doctor know that your sleep or appetite is disrupted, or that you are experiencing other side effects that can lead to depression, such as nausea, this may enable the treatment team to make helpful changes in your medical management. Don't hesitate to express your feelings and symptoms to your medical team.

Will depression end when therapy is over?

Question from Candy: How long does depression tend to last when it's brought on by medication? I keep thinking my depression will end once my therapy concludes.

Answers —Diane Thompson, M.D.: We do know that women who are undergoing chemotherapy are more likely to have symptoms of depression, and these do tend to improve after chemotherapy is over. However, there is no specific timeline. Some women feel much better within several months of completing treatment, while others complain of a "foggy brain" for much longer. Regardless, if you're experiencing symptoms of depression during or after treatment, please discuss it with your physician, since this may be a good time to start some type of treatment.

Jennifer Griggs, M.D., M.P.H.: In thinking back on their lives, some women have told me that they think they were actually depressed for years even before their breast cancer diagnosis. Sometimes a breast cancer diagnosis is a window of opportunity that can enable a person to get appropriate treatment for a chronic condition. Look at this as an opportunity for help if this description fits.

Rosalind Kleban, L.C.S.W.: I have seen women in dealing with breast cancer being able to acknowledge their depression, take antidepressant medication, and tell me they actually feel better than they have for years prior to the breast cancer diagnosis. I think these are people who have suffered from dysthymic conditions, and it took the crisis of breast cancer to encourage these people to ask for help. I would also like to add that I commonly see patients continue to have feelings of sadness, fear, and vulnerability, often up to a year after treatment is over.

It's very much like mourning, in that the response is similar to that of loss. Having a cancer diagnosis represents many losses. There's a loss of invincibility, loss of trust in your body, for many women a loss of a body part, and gradually over a period of time, often as much as a year, people in a gradual way start to get back to themselves and get back to their normal lives.

Jennifer Griggs, M.D., M.P.H.: Women who are finishing treatment often expect to feel happy and joyous. When they don't, because it takes a while, that disconnect between what they expect and how they actually feel sometimes makes depressive feelings even stronger.

Rosalind Kleban, L.C.S.W.: It's helpful to warn patients that anxiety often increases when treatment is over. It's actually a rare patient who is ready to celebrate upon the completion of chemotherapy.

Jennifer Griggs, M.D., M.P.H.: I wholeheartedly agree!

Diane Thompson, M.D.: Often after patients are done with chemotherapy, they tell me they felt more secure while they were getting treatment because they felt so awful they were sure the chemotherapy was doing something. When it ends, they may feel helpless. It's at this point that I urge people to enter the next stage, which is the stage of wellness and recovery from treatment. This is where choosing an appropriate diet and exercise can be good activities for the patient to focus on.

Jennifer Griggs, M.D., M.P.H.: I make the distinction for patients that at this point the cure may have happened, but the healing may just be starting. What we're all trying to say is that you're on schedule, but if you believe your depressed feelings are lasting too long, don't hesitate to say something to your doctor.

Rosalind Kleban, L.C.S.W.: This is also a good time to look for a post-treatment support group. Often friends and family don't understand the feelings patients may have, and think the patient should only feel celebratory since treatment is over. However, other patients certainly understand the feelings of fear, anxiety, and even abandonment by the medical community that are so common at this time.

Who can address emotional pain?

Question from Soulright: My medical team only addresses my body. Who takes care of my emotional pain?

Answer —Rosalind Kleban, L.C.S.W.: The first thing to do is address that question to your medical team. All patients are more than their cancer, and the illness can't be fully addressed if the whole person is ignored. I would ask my physician to direct me toward the kind of emotional help and support that is essential during breast cancer treatment. Many hospitals and local American Cancer Society chapters offer support groups for women with breast cancer. Lacking that, websites such as Breastcancer.org are wonderful places to connect with other patients.

Which antidepressant is right?

Question from Falla: I'm considering asking my doctor to prescribe antidepressants for me, but there are so many medications out there that I have no idea which one might be right for me.

Answer —Diane Thompson, M.D.: I'm glad to hear that you and your doctor are going to discuss this. There are many excellent antidepressant medications on the market today. In fact, they are so good that at this point we often choose an antidepressant based on its side effects. Some side effects may actually be good. For example, some antidepressants can help with sleep while others are more energizing. Some may decrease appetite, and others may increase appetite. These are some of the issues that you may want to discuss with your doctor when choosing an antidepressant.

Metastasis automatically means depression?

Question from Angela S: My sister's been living with metastatic breast cancer for three years. She says she's doing okay emotionally, and she's functioning okay. But wouldn't this situation make just about anyone depressed? I keep telling her she should get some counseling, but she refuses. Should I just drop it?

Answer —Rosalind Kleban, L.C.S.W.: I work with many women who have metastatic or advanced breast cancer who are not depressed. So while you and I may look at this situation and feel that it's understandable and appropriate to be depressed, many people are not. Is your sister able to enjoy life? Does she find pleasure in things that have traditionally been good for her? Breast cancer is often a chronic illness, and many women live a very long time with it while leading functional, productive, good lives.

While it's certainly quite difficult to have advanced disease and to be on and off treatment for years, it doesn't need to be the end of the world, and it doesn't have to come with depression. Advanced disease is an issue that is rarely addressed by organizations devoted to breast cancer patients. I believe that this is a mistake and a problem that needs to be addressed by the healthcare community.

Where to go for free counseling?

Question from L Penner: My health insurance doesn't offer reimbursement for mental health services, but I really need to talk to someone. Where can I go to get free or very inexpensive counseling?

Answer —Rosalind Kleban, L.C.S.W.: Many community-based family service agencies offer inexpensive and sliding-scale fee schedules. Also, support groups for cancer patients are often free, and I think that is what I would recommend at this point.