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

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

In this home care plan, we discuss some ways to tell when to seek medical help. We also discuss some ways that you can help limit or manage depression.

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

It is important to pay attention to your own emotional health if you are to do your best as a caregiver.

Your goals are to:

• keep an eye out for early depressive symptoms and manage depression early before the symptoms become severe.

When To Get Professional Help

Symptoms that indicate that professional help is needed

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

• You have been depressed before this illness and have had at least two of the following symptoms consistently during the past 2 weeks:

1. Feeling sad most of the day
2. Loss of interest in almost all daily activities
3. Difficulty paying attention to what you are doing and trouble making choices.

If you have a history of serious depression before your child's illness, you are vulnerable to depression. Having a child with a serious illness like cancer may trigger your depression, in which case, professional help will be needed.

• You notice wide mood swings from periods of depression to periods of agitation and high energy.  Some people who have wide, uncontrollable swings in mood may have a "manic-depressive" illness. They cycle between being depressed with low energy and having a great deal of energy with feelings of agitation or feeling "high." The moods often don't seem connected to what is going on around the person. This requires professional help to determine if medication is necessary.
• Nothing you do seems to help, even those strategies that have worked for you in the past.

How To Get Professional Help

Getting help for depression is just like getting help for physical problems. Asking for help doesn't mean you are crazy. The problem could be caused by the stress related to caregiving, which is an understandable reaction to the serious issues you must face.

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

• Ask for help from a family doctor or another physician who is familiar with you and your child's illness. Physicians can evaluate whether anti-depression medications may help and can prescribe them if necessary.
  
• Ask a mental health professional such as a social worker, psychologist, or psychiatrist for help. Mental health professionals are experienced in helping people with many types of emotional problems. They can be especially helpful when there is a history of depression before the illness. Many psychologists, social workers, and other mental health professionals have experience working with parents of young people with cancer. They can be very helpful when depression is a reaction to the stress of the illness.

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

What You Can Do To Help

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

How to prevent or decrease depression

Much of the work here has to come from yourself. Following are methods that you can use to prevent or decrease depression. These techniques work for most people.

• Act before depression becomes severe If you ignore the early signs of depression, it is more likely to get out of hand, to seriously affect your quality of life, and to require professional help.
  
• Schedule positive experiences for yourself Keep doing things that make you feel good. Don't become so involved in your caring responsibilities that you neglect your own emotional health. Don't feel guilty about taking care of yourself. If you become overwhelmed, you won't be able to provide care and support. You will be a better caregiver if you take time to do things that you enjoy outside of your caring responsibilities. If you start feeling overwhelmed, take time off to do the things you enjoy. Do this early. This can help prevent your becoming seriously depressed and give you the strength to carry on.
  
• Help increase the number of activities that you do with other people Being with people you know and enjoy is an excellent way to take attention away from negative thoughts and feelings. It provides opportunities to think about one's own life in comparison to others and to recognize the good things in one's life. It provides opportunities to give as well as to receive help, to share experiences and perspectives, and to get help in dealing with problems that are making you depressed. Most important is that other people can express caring and love. Knowing that other people care and are available to help when needed gives people strength and confidence when facing an uncertain future.

Three types of people can be especially helpful. Make a list of friends and family members using the following categories.

1. People who are sympathetic and understanding
2. People who give good advice and who can help solve problems
3. People who can turn route attention away from problems and toward pleasant experiences.

• Set reasonable, attainable goals Depressed people tend to set goals that are too high, and when they don't reach their goals, they tend to become even more depressed. When you plan positive experiences, be sure that your goals are reasonable. It is better to set a low goal and accomplish more than you expected than to set too high a goal and fail.
  
• Control repetitive, negative thoughts and substitute positive experiences and thoughts
  Five techniques for controlling negative thoughts are explained at the end of this home care plan. They are:

1. Thought stopping-to control repetitive negative thinking
2. Arranging a plan and time for negative thinking-to control and limit negative thoughts
3. Distraction-to take attention away from negative thoughts
4. Arguing against negative thinking-to show yourself how unreasonable your negative thoughts are
5. Solving day-to-day stressful problems that can be a cause of negative thoughts.

Possible Obstacles

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

Here are some obstacles that other people, like yourself, have faced in dealing with depression

1. "My problems are real! It's normal to be depressed in my situation."
   
   Response: Your problems are real and some depression is normal. But getting stuck in the feeling of depression can interfere with dealing with the problems that are causing the depression. The goal is to keep a balance between positive and negative thoughts. The problems are real, but many of the good things in life are also real and should get equal attention.
   
2. "Nothing will help, so it's no use trying."
   
   Response: Give it a try! There is nothing to lose and a good deal to gain. Start with things that are easiest to do. Then judge if these ideas are helpful. If your are so depressed that you can't even try, then professional help is probably needed.

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

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

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

Carrying Out and Adjusting Your Plan

• Talk this plan over with someone you trust. Together you should agree on what you can do together to manage depression. It is important to work as a team when dealing with these problems. Sometimes the support and the feeling of being on a team is in itself helpful.
  
• Use these techniques early.Look for beginning signs of depression and put your plan into action then-don't wait until depression is severe. The techniques discussed in this plan have helped severely depressed persons, but usually as part of professional treatment.
  
• Plan in advance what you will do to manage depression. If you know that you are likely to be depressed at certain times based on past experience, then make plans for what you will do to prevent depression from building up.
  
• Persist. Even if you continue to feel depressed, don't give up. You are probably preventing the depression from getting worse. Keep working cooperatively with someone you trust. If you are working together, these ideas can only help.

Checking on results

• Talk regularly about your feelings. Although it may be difficult for you at first, talk about your feelings. It may seem scary at first to talk about what is upsetting. But it's important to do this because it helps you to control depressed thoughts and feelings.
  
• Watch for indications that professional help is needed.

If your plan doesn't work

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

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

Techniques for Controlling Negative Thoughts

• Thought Stopping
• Arranging a time and a place for negative thinking
• Distraction
• Arguing against negative thoughts
• Solving day-to-day problems that are causing you stress

Thought stopping

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

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

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

• Yell "STOP" really loudly in your mind. Yell STOP when you scream STOP in your mind; pretend it is very loud. The idea is to wake you up, to make you aware that you're in danger of getting stuck in negative thoughts. You might start this by going to a place by yourself and shouting STOP out loud. Practice it this way until you can do it in your mind alone.
  
• Visualize a big red STOP sign. Try to see it clearly, and then get your mind on something else. Think of what a STOP sign looks like. Make sure you see it as a red sign. Practice seeing it in your mind so that you can bring it to mind easily. Now whenever you catch yourself starting negative thoughts, think of this image and stop yourself.
  
• Slap yourself on the wrist with a rubber band. Another way to remind yourself to stop is to gently slap your wrist with a rubber band. This isn't to punish yourself. It's to give you a physical reminder to stop the thoughts.
  
• Splash some water on your face. Splashing water in your face is another way to wake yourself up from the negative thinking. Pay attention to how the water makes you feel. And stop your negative thoughts.
  
• Get up and move to a new spot. Getting up and moving to a new spot gives you a change of scenery. You can use the new surroundings to help you think about other things.

You have to fight the negative thoughts. Maybe several of these techniques together will work for you. When you're depressed, you may look at techniques for stopping these thoughts and say, "That's silly. It could never work." Actually, research has shown that they can work. Give them a try!

Arranging a time and a place for negative thinking

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

• Find a negative-thinking "office." This can be a room, a chair, or just a certain window. Make this the only place you let yourself think about all of the negative things.
  
  Your "office" space can be any place you choose. Don't, however, make it your bed or your seat where you eat. These need to be "safe zones." Now you should try to only think your negative thoughts in this one place.
  
• Schedule a time each day when you plan to think your negative thoughts. Scheduling a time to think about your negative thoughts helps you to take control of them. You might not be able to control all negative thinking, especially in the beginning. But this technique will gradually help you to get control over your negative thinking.
  
  Don't make this time around mealtimes, just before you go to sleep, or just before you expect to see people. These should be relaxing times. Make this time no more that 15 minutes. At the end of 15 minutes, stop. You can continue tomorrow.

Distraction

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

• Take a vacation in your mind. Close your eyes and think about your favorite spot. Spend a couple minutes there on a mental vacation. Relax and enjoy it.
  
• Mental time travel into the future. Think of something that you are looking forward to. Imagine that it is happening. Think of how nice it is to be there.
  
  When you take your mental vacation or time travel to something you're looking forward to, really try to work your imagination. Think about as many details as possible.
  
  What does it feel like? Is it a warm breeze? Imagine how it feels on your skin.
  
  What does it sound like? Are there waves gently crashing on the beach? Are people laughing, or is music playing? Imagine it as clearly and vividly as you can.
  
  What does it look like? Is the sky clear and blue? Or are you in a room? Imagine what the room looks like. Try to see it as completely as you can.
  
  What does it smell like? Is it the salty smell of the ocean? Maybe you smell the fragrances of a garden or a big dinner. Make it as clear as you can.
  
  What does it taste like? Are you drinking a nice cool drink? Feel it in your mouth. Taste it.
  
  Use these exercises to fill your mind with as many pleasant details as you can. Think of as many as you can. This exercise is also helpful when you are feeling anxious and need help falling asleep.

• Tension busting. Use the relaxation exercises in the home care plan for Parents' Anxiety. Being relaxed helps you to think about pleasant things.
  
• Do something you like. Really get yourself involved in an activity you like.
  
  The idea of this exercise is to fill your mind up with positive thoughts and to have them crowd out the negative ones.

Arguing against negative thoughts

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

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

• Is your negative thought really true? Make yourself be clear about what evidence supports it.
  
• Now take the other side. Argue the exact opposite. Think of every reason why your thought may not be true or may be exaggerated. Don't give up too easily. Really argue as if you were arguing with someone else.
  
  When you're arguing with your negative thoughts, try to be as complete as possible. You may want to write down the answers to the following questions:
  
  What is the evidence against my negative thought?
  
  Are there any "facts" in my thinking which are really just assumptions? Is my argument an example of "black and white" thinking? Are there shades of gray that I'm ignoring?
  
  Is the negative side taking things out of context? Am I looking at the whole picture or just one small part of it?
  
  Am I trying to predict the future, when I really know that I can't?
  
  Try to punch as many holes in your "negative sides" argument as you can. Don't accept any illogical thinking at all.

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

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

The home care plan on Solving Problems Using the Home Care Guide for Young Persons with Cancer at the beginning of this book explains how to use four problem-solving steps to deal with problems that are not included in this workbook. The four steps are:

• Get information from cancer care experts about the problem and what you can do (the kind of information that is in the home care plans)
• Develop your plan in an orderly way, including reviewing the facts, setting reasonable goals, and choosing the strategies that are the best balance between risk and benefit. When you encounter obstacles, you should:
• Keep a positive outlook
• Be creative by seeing the problem from someone else's perspective, asking other people for ideas, and rethinking your expectations.

You can remember these ideas with the word COPE:

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

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