Mood anxiety and depression
Low mood, anxiety and depression are common. The WHO recently estimated this to be up to a third of the population in Western style societies, at any one time. As the nights get longer in Northern countries the incidence of depression increases. This is thought to be related to lower melatonin and serotonin levels leading to disruption of circadian rhythm.
Mood dysfunction is also more common after diagnosis of a chronic disease. As well as being distressing for the patient and carers, depression has also been shown to be associated with a reduced survival from cancer and heart attacks compared to those who are psychologically healthy.
Sometime there are no obvious causes but medical factors 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 before a routine 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, fatigue or depression can be aggravated by steroid withdrawal. 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.
Lifestyle factors affecting low mood anxiety and depression
1.Blood Sugar and Insulin Dysfunction
Processed sugar in the form of sweets, cakes or sugar itself leads to an excessive caloric intake. When your cells are constantly flooded with excess energy, they eventually say, “enough is enough” and refuse to take in more energy. This is the state of insulin resistance and, further down the road, diabetes (type‑2).
Research from Scandinavia has uncovered a clear association between elevated HbA1c — a three-month average of your blood sugar levels — and insulin levels with increased risk of depression.
They found that young men with insulin resistance were three times more likely to suffer from severe depression.(1) Another study in Diabetes Care of over 4,000 people showed depressive symptoms were highly associated with higher fasting and 30-minute insulin levels.(2) The authors specifically noted that antidepressant medications did not alter this association because the medications target neurotransmitters (e.g. serotonin, dopamine) and do not address blood sugar and insulin dysfunction. Improving blood sugars and insulin control is an important first step for reducing your risk for low mood and depression – See tips to lower blood sugar
2. Chronic & Systemic Inflammation
Inflammation is another potential root cause of low mood. Low-grade systemic inflammation leads to the over-production of pro-inflammatory cytokines that are also associated with depression.(3) The prestigious New England Journal of Medicine published a review of the growing connection between chronic inflammation and the development of today’s most common chronic diseases, including depression.(4)
The current medical literature tells us that if you are overweight or obese, you likely have low-grade systemic inflammation.(5) This shouldn’t be a surprise, as inflammation is “upstream” of blood sugar and insulin dysfunction.
A diet rooted in traditional foods — rich in animal protein, healthy fats and antioxidants — will help to cool inflammation and reduce the damaging effects of reactive oxygen species (ROS) produced during the inflammatory response. Polyphenols found in coffee, dark chocolate (even red wine!), as well as vegetables are great sources of anti-inflammatory polyphenols. Extra-long chain omega‑3 fats, such as DHA and EPA, also exert powerful anti-inflammatory effects, and a poor omega‑3 to omega‑6 fats ratio is also associated with a chronic stress state and increased risk of depression. (6) – tips to reduce chronic inflammation
3. Gut Dysfunction & Dysbiosis
The gut microbiota — commonly referred to as your microbiome — plays a key role in your mental health through its constant communication with the brain via the vagus nerve. Key neurotransmitters targeted by medications for improving symptoms of depression – serotonin and dopamine – are actually produced in the greatest concentrations in the gut (not the brain).
This gut-brain axis is highlighted by research showing poor gut health, leads to poor zonulin function, a key molecule that regulates gut permeability.(7) Poor zonulin function leads to symptoms of a leaky gut, leading to a pro-inflammatory environment that creates the cytokine storm that contributes to low mood and depression.
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
4. Food intolerances and leaky gut syndrome
As we get older, it is more common to develop an intolerance to gluten found in wheat and other grains, while our ability to metabolise lactose in milk also falls. Both of these situations can increase gut inflammation, leading to Irritable Bowel Symptoms (IBS) such as bloating, unsatisfactory bowel movements and fatigue. Keeping a food diary can help identify which foods trigger these symptoms. If gluten is found to be problematic, reduce the intake of bread, pasta and cereals. If milk is suspected, change to fermented products which have already had the lactose broken down and are easier to digest. Probiotic supplements such as Lactobacillus acidophilus help with the digestion and absorption of lactose by producing lactase. Chronic exposure to food you are intolerant to will lead to gut inflammation and leaky gut syndrome
You don’t need to have a food intolerance to suffer from leaky gut. If you travel across multiple time zones, consume alcohol excessively, or chronically rely on NSAIDs – non-steroidal anti-inflammatory drugs – like ibuprofen and naproxen you’ll be much more prone to leaky gut and chronic worsen inflammation.(8,9) A dietary approach rooted in traditional foods — animal protein, healthy fats, vegetables and unprocessed carbohydrates — will help to keep blood sugar levels balanced and support a healthy gut microbiota, thus keeping systemic inflammation and low mood at bay. – tips to improve gut health
5. Exercise and avoiding a sedentary Lifestyle
Exercise, in particular, has been shown to help alleviate mood and reduce anxiety and fear, especially if they involve group activities. A recent meta-analysis of 92 studies on more than 4,310 people showed that light to moderate exercise significantly reduced the incidence of depression. (10) Try adding 15 – 20 minute walks at lunch or the end of your day to increase your activity level. Another 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. A further 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.
Strength training can also play a key role in mental health. Basic movements like squatting, lunging, bending, pushing, and pulling are deeply engrained in our DNA and exert tremendous positive benefit on multiple systems of the body: improving blood sugars and insulin, reducing inflammation, boosting testosterone (low levels have been associated with depression), and supporting healthy gut flora. If you’re not active, start slowly with 10 – 20 minutes of strength training 2 – 3 times weekly and focus on bodyweight type movements.
6. 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. There are some interesting early trials which suggest that full spectrum hemp oil combined with exercise and a low inflammatory diet can reduce stress and help sleep.
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”.
7. 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
8. Good nutrition
There is some evidence that low levels of omega 3 and 6 in the diet can increase the risk of depression . So it’s a good idea to ensure adequate intake of oily fish and oil plants such as avocado (read more about how to increase healthy fats and reduce unhealthy fats ). Pulses and grains if not gluten intolerance are good. Whereas too much meat can increase the risk of chronic inflammation a recent study showed that vegans have a higher risk of depression so fish or meat once or twice a week, in terms of mood, is a good thing.
There is also some evidence that deficiencies in vitamins, minerals and other micronutrients can cause dysfunctional brain activity. As well as a balanced diet with lots of fruit and vegetables and nuts many people are turning to micronutrient testing. Finally, polyphenols have direct anti-inflammatory, sugar lowering and gut improving properties so they can help mood. – tips to improve polyphenol intake
9. Vitamin D and sunlight exposure
Recently, vitamin D has been reported in the scientific and lay press as an important factor that may have significant health benefits in the prevention of depression. Most individuals in the UK have insufficient levels of vitamin D. This is also true for persons with depression as well as other mental disorders. Whether this is due to insufficient dietary intake, lifestyle (e.g., little outdoor exposure to sunshine), or other factors is addressed in this paper. In addition, groups at risk and suggested treatment for inadequate vitamin D levels are addressed. Effective detection and treatment of inadequate vitamin D levels in persons with depression and other mental disorders may be an easy and cost-effective therapy which could improve patients’ long-term health outcomes as well as their quality of life. – Tips to increase vitamin D levels
There is also evidence that walking or exercising outdoors can help maintain a normal circadian rhythm especially after a long haul flight or disturbed night sleep for other reasons. Sleep hygiene tips
10. Maintain a healthy weight
Several studies have linked obesity with low self-esteem, lower mood status and subclinical depression. Low mood, independent of other factors, contributes to oxidative stress and inflammation, while also reducing the incentive to change to more weight controlling behaviours such as eating less and being more active. The RAINBOW study from the USA published in 2019 showed that an intervention which helped weight loss also improved mood and incidence of depression to some extent . We also know that being overweight is also associated with poorer gut health. As well as being distressing, low mood and depression a study, published in the Oncologist in 2019 found that patients with cancer severe depression was associated with a 30% worse survival. – tips to maintain a healthy weight
Summary – 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.
- Take regular light exercise
- Avoid sugary foods and protect your self from diabetes
- Take part in regular social activities
- Maintain an interest or hobby
- Each a prudent polyphenol rich 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 or mindfulness counsellor
- Avoid excess alcohol
- Avoid coffee and strong tea
- Stop cigarettes and other recreational drugs
- Review medications with your doctor
1. Timonen. M et al. Insulin resistance and depression in young males: Findings from Finnish military conscripts. Psychosom Med 69(8):723 .
2. Pyykkonen AJ et al. Depressive symptoms, antidepressant and insulin resistance: the PPP-Botnia Study. Diabetes Care. 2011 Dec;34(12):2545.
3. Felger J, Lotrich FE. Inflammatory cytokines in depression: neurobiological mechanisms Neuroscience. 2013 Aug 29;246:199.
4. Emerging Risk Factors Collaboration. Diabetes mellitus, fasting glucose. New England J Medicine, Mar 2011;364;9:328.
5. G. S. Hotamisligil et al “Adipose expression of tumor necrosis factor‑α: direct role in obesity-linked insulin resistance,” Science, vol. 259, no. 5091, pp. 87 – 91, 1993.
6. Larrieu T, et al. Nutritional omega‑3 modulates neuronal morphology and depression-related behaviour via corticosterone secretion. Transl Psychiatry. 2014 9;4:e437.
7. Moreno-Navarrete JM et al. Circulating zonulin, a marker of intestinal permeability, is increased in insulin resistance.. PLos One 2012;7(5):e37160.
8. VanWijck K et al. Aggravation of exercise-induced intestinal injury by Ibroprofen in athletes. Med Sci Sports Exerc. 2012 Dec;44(12):2257.
9. Ma et al The rainbow diet and depression: