Cancer survivors may be at high risk of suicide, even if they show few signs of depression, according to experts.

You’ve finished cancer treatment. You’ve been declared “cancer-free.”

Now what?

Life after cancer may not be quite what you expected.

You may also wonder if you’re living up to others’ expectations.

The emotional effects of cancer can differ, but suicidal thoughts are not uncommon.

Christopher Recklitis, Ph.D., MPH, of Harvard Medical School and the Dana-Farber Cancer Institute, spoke about suicidal ideation in cancer survivors at the 2015 World Congress of Psycho-Oncology.

According to Recklitis, these thoughts can happen even where there are no obvious signs of depression. That’s why they’re easy to miss.

A survey conducted as part of the Childhood Cancer Survivor Study found a higher rate of suicidal ideation in cancer survivors than in control groups.

That held true even many years after diagnosis. People in pain or poor physical health were more likely to have those thoughts.

In a survey of prostate cancer survivors, Recklitis and his colleagues found that 12 percent of respondents experienced suicidal ideation in the previous year.

Physical and emotional health, pain, work status, and income were found to be contributing factors.

Depressed mood was linked with suicidal ideation. So was having a previous mental health condition

There was no link between suicidal ideation and age. Type of treatment, recurrence, or time since diagnosis didn’t matter.

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New York actress Jacey Powers was diagnosed with breast cancer in 2013. Now 27, she’s been cancer-free for a year and a half.

“I’m happy and healthy,” she told Healthline. “But there have been many bumps in the road.”

Life after “you’re cured” isn’t the relief you expect it to be, said Powers. She believes it’s common for survivors to feel depressed and to question why they’re alive.

“After a year of fighting, and to some extent defining myself as a person fighting this illness, where do I go now? What’s the next fight? The questions can feel overwhelming,” she said.

Powers is grateful to those who were wise enough to lend support beyond her initial treatment.

When we think of treating cancer, we think of the body. The psychological part is usually an afterthought.

“Cancer survivors, as well as survivors of cardiac events or other major medical diagnosis, often spend time and energy on medical treatment for the physical illness, and not on the mental health component associated with this life changing event,” therapist Cara Maksimow, LCSW, CPC, told Healthline.

“Identifying mental health needs related to stress, anxiety, and depression around any medical illness is important to recognize,” Maksimow said. “Treating the stress and depression can affect all aspects of health.”

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Cancer can be a traumatic experience.

It can have long-lasting emotional effects, according to Lekeisha A. Sumner, Ph.D., ABPP, assistant clinical professor at the Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles.

As a board-certified clinical psychologist, Sumner has treated cancer survivors and conducted psycho-oncology research involving them.

But signs of depression can be difficult to detect.

Sumner said symptoms of depression might overlap with other aspects of cancer or cancer treatments. These include fatigue, pain, and sleep disruptions.

“Also overlooked are the symptoms of anxiety (largely about recurrence and role functioning) and cognitive impairments (e.g., difficulties with thinking clearly, concentration and/or memory),” she told Healthline.

There may also be some residual grief from the cancer experience. Survivors may also feel the strain of expectations others have about how survivors should function after treatment.

“This exacerbates symptoms of depression, anxiety and adjustment that if left untreated may result in suicidal ideation,” said Sumner.

After treatment ends, survivors should still have regular doctor visits. It’s helpful to talk openly about emotional distress.

“Openness to working with a mental health professional with expertise in psycho-oncology has been shown to be an effective intervention,” said Sumner. “It can facilitate stress management, adjustment, effective coping, and process the grief commonly experienced.”

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Ben Michaelis, Ph.D., a clinical psychologist and author of Your Next Big Thing, spoke with Healthline about the warning signs of suicide.

“If someone you know talks about killing themselves, having no reason to live, feeling like things would be better if they weren’t there, feels trapped, or says that they feel like a burden to other people,” said Michaelis, “those are clear warning signs.”

Others are social withdrawal, giving away possessions, and calling to say goodbye.

“Try to connect them with either a mental health professional, a primary care provider, or the American Foundation For Suicide Prevention,” said Michaelis.

When you learn you have cancer, the focus is on physical survival. When treatment ends, the psychological effects can intensify.

Cancer survivors often feel pressure to be grateful for being alive. Guilt and fear of appearing ungrateful may keep them from seeking the help they need.

“If you’re a cancer survivor thinking about suicide,” Michaelis said, “you are not alone and there is help out there. Lots of it. It’s just a matter of letting someone know what you are going through.”