Mood, Anxiety and Depression
Low mood, anxiety and depression are common and often unrecognised after cancer but when looked for specifically reported prevalence rates can be up to 25-30%. As well as being distressing for the patient and carers, depression has also been shown to be associated with a reduced survival compared to those who are psychologically healthy. The best example of this was highlight in an observational trial from California, which evaluated the records of 41,275 men with prostate cancer. They found 1,894 men with an associated proven diagnosis of depressive illness who had 40% higher prostate cancer death rate compared to non-depressed men. Interestingly, the greater difference was seen in the men with the least aggressive, less worrisome, disease. The authors suggested that the progression or relapse of indolent cancers were more likely to be influenced by lifestyle and psychological factors and that psychological morbidity after cancer does not depend on the severity of the cancer.
The cause of psychological morbidity is pretty obvious. Being told you have a life threatening illness which requires aggressive treatments, years of toxicity risking physical and financial ruin is enough to trigger anxiety and depression even in the most level headed individuals. Other factors, however, can specifically contribute to anxiety such as steroid agitation, allergy to drugs and withdrawal from sedatives. Even in the follow up period anxiety is common per a scan and in the period waiting for results – Doctors should consider “scanxiety” when requesting scans and try to shorten the time before results are given. Low mood or depression can be aggravated by steroid withdrawn, fatigue, poor sleep patterns, treatments that put women into menopause or reduce testosterone in men such as after chemotherapy, surgery or more usually hormone therapy. Unless a lower testosterone is needed, as in the treatment of prostate cancer, testosterone replacement therapy can be a major help improve mood and motivation in men. In post menopausal women with breast cancer Aromatase inhibitors can lower mood but our own research has shown that different brands of breast cancer drugs, even within the same category, can be tolerated differently from one person to another so it may help to ask for a change. Above all, before any hormone therapies are started patients should be warned of the psychological consequences as intervention studies, particular with increased exercise can prevent them.
Ideally psychological health should be routinely screened for at all stages of cancer management. A particularly risky period is shortly after the end of the initial course of intensive therapies, such as after the last cycle of adjuvant chemotherapy for breast or bowel cancer, where the sudden end to hospital support may make you feel at your most vulnerable. Clinical psychologists and psychological counsellors are now available in most cancer units who can offer interventions and treatments but in the UK most GP’s are more than capable to offering help to individuals with uncomplicated anxiety and depression and they should be the first port of call if your mood is low and especially with its affecting your day to day life.
What can you do to help?
In the first instance vocalise your anxiety or depression with your cinical nurse specialists, oncologist and GP as therapeutic interventions can be considered. Early recognition of symptoms and appropriate counselling, support and treatment helps to stem the decay in self-esteem, and relationship issues within the family and work place. The more commonly recognised self-help strategies include support groups, relaxation classes and mindfulness which help directly or indirectly re-channel your negative energy or fear into positive enthusiasm for lifestyle and exercise.
Exercise, in particular, has been shown to help alleviate mood and reduce anxiety and fear of relapse, especially if they involve group activities. For example, a recent meta-analyses of RCT’s involving women with breast cancer reported a 15% reduction in depression scores following group or supervised exercise classes. Another study involving 1966 patients with colorectal cancer achieving at least 150 minutes of physical activity per week had better mood scores and an 18% higher quality of life scores than those who reported no physical activity. Another study showed similar benefits for patients who had recently completed surgery, radiotherapy or chemotherapy. Another interesting aspect of this study was that improvements in peak oxygen consumption correlated directly with changes in mood and overall QOL suggesting a dose response between exercise and mood i.e the more exercise the better the mood. In terms of anxiety alone, analysing data from 40 studies imvolving 3,000 participants reported that exercise in sessions of at least 30 minutes of exercise three times a week, had a 20% reduction in anxiety symptoms compared to those who did not exercise. The effect was greater amoung patients who were sedentary before the start of the intervention suggesting getting people off the cough and doing something is still a big advantage. Exercise reduced anxiety, no matter what kind of health problem they had including cancer, heart disease, or fibromyalgia. As in the depression studies, exercise longer than 30 minutes was even better at providing relief from anxiety than shorter sessions. So again it looks like the more the better. The underlying reason for the benefit may lie in the release of positive brain chemicals (neurokins) that make people euphoric. Exercise is also generally fun, gets people out of the house – socialising and interacting with other people. ..read more about exercise
Mindfulness-based stress reduction (MBSR)
MBSR done properly elicits a relaxation response (RR) that is characterized by decreased oxygen consumption, increased exhaled nitric oxide, and reduced psychological distress. MBSR therapy was investigated in a prospective controlled study involving 84 women with breast cancer. The half randomised to a 6-week MBSR programme had significant better mood compared to those on standard care. Researchers from the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital went a step further with a fascinating study which looked at the difference in expression of over 2000 genes within three groups – no intervention, a short 8 week intervention, long term interventions. Both interventions had favourable (epigenetic) alterations in gene expression but the positive effects were most marked in the long term group. These genetic changes were associated with reduced oxidative phosphorylation (lower cellular metabolism) and reduced formation of reactive oxygen species is thought could counteract cellular damage related to chronic psychological stress.
Yoga was investigated in a small RCT involving women with breast cancer demonstrated a significant decrease in anxiety states and improvements in QoL following surgery in the group randomised to regular yoga classes group as compared to controls.
Dietary interventions combined with exercise were investigated in a prospective trial of 252 younger women with breast cancer. Women randomised to high vegetable low fat (prudent diet) had lower intrusive depressive thoughts, concerns regarding cancer recurrence and mortality, better self-concept perceptions, and self-efficacy expectations.
Probiotic healthy bacteria has been the subject of much attention recently as more an more evidence is emerging for a link between gut health a healthy mind, not just depression but cognitive function (intellect) and neurological conditions such as dementia, Parkinson’s disease. The associate is not however new, there have been reports of benefit dating back to 1923 of acidophilus rich milk helping patients with psychoses. Study involving mice conducted by the Alimentary Pharmabiotic Centre in University of Cork showed that those fed with Lactobacillus had significantly fewer stress, anxiety and depression-related behaviours than those fed with standard feed. Moreover, bacteria fed mice had lower levels of the stress-induced hormone, corticosterone and had altered expression of receptors for the neurotransmitter GABA in the brain. In humans, a study from The University of California, showed that healthy women consuming probiotic-containing yogurt were reported to have improved brain function and less environmentally induced markers of stress ..read more about probiotic bacteria
Massage especially those combined with exercise such as yoga or Pilates, are excellent remedies for anxiety and the muscle tension associated with it. Hands-on complementary therapies such as massage, reflexology and acupuncture have also shown improvement in anxiety in fairly robust analyses. Note that despite common folk-lore, gentle massage is safe and there is absolutely no evidence that it “spreads cancer cells around the body”.
Smoking, alcohol and illegal drugs: Contrary to popular opinion amongst smokers, cigarettes greatly increase anxiety. It is a myth that smoking calms your nerves. This only appears to be the case because even a few minutes after smoking a cigarette, the body begins to ‘withdraw’, leading to tremors, sweating and anxiety which can only be relieved, momentarily, by another cigarette. This leads to an escalating spiral of increased cigarette dependence, followed by more anxiety and the only way to stop it is to give up. Although a small glass of wine or beer with friends can lead to better social interaction Excess alcohol and other illegal recreational drugs such as cannabis, cocaine and heroine most other illegal agents leads to problems. When the pleasant effect wears off, particularly if associated with a hangover, it can makes you irritable, with significantly lower your mood, withdrawal anxiety or even triggering depression. This explains why suicide rates are considerably higher amoung heavy smokers, alcohols and illegal drug users.
- Take regular light exercise
- Take part in regular social activities
- Maintain an interest or hobby
- Each a prudent healthy diet
- Eat healthy bacteria and consider a probiotic supplement
- In men without Ca prostate consider androgen replacement therapy
- Try to maintain good sleep hygiene habits
- Consider investing in a psychological counsellor
- Avoid excess alcohol
- Avoid coffee and strong tea
- Stop cigarettes and other recreational drugs
- Review medications with your doctor