Stress, Depression & PTSD

The depth and duration of stress may lead to depression, which occurs at a rate approximately three to five times greater in cancer patients than the general population, says Michael Irwin, MD, director of The Cousins Center for Psycho­neuroimmunology UCLA Semel Institute for Neuroscience and Human Behavior. “Unfortunately, depression remains largely underdiagnosed and undertreated in cancer patients, and chronic depression might impact disease progression,” he says.

Michael Burke, MD, clinical director of psychiatric oncology at the Emory Winship Cancer Institute in Atlanta, says there is a difference between a depressed mood, which is transient, and the syndrome of depression, when patients report a sadness or lack of interest as well as significant changes in four or more brain-regulated functions, such as mood, cognition, sleep, appetite, self-image, psychological thought patterns, energy, concentration, memory, decision-making, interest, motivation, and self-protection.

“Few would ignore cardiac symptoms if they were in the middle of cancer treatment. Why ignore brain symptoms like depression that can be effectively treated so the person can feel better during a difficult time?” Burke says.

Barbara L. Andersen, PhD, a professor of psychology at Ohio State University in Columbus, conducted a separate analysis of women with breast cancer who showed major depression as part of a larger study to determine if psychological interventions impacted survival. What was discovered, she says, was that reducing stress and depressive symptoms resulted in a better immune profile, meaning how well the immune system is functioning, and psychological profile. “The reduction in symptoms at four months and then measuring inflammation at eight and 12 months showed that when we reduced the depressive symptoms early, then later on, inflammation was less.”

Aside from depression, Burke says 3 to 10 percent of adult cancer patients have post-traumatic stress disorder (PTSD), an anxiety disorder that develops in reaction to physical injury or severe mental or emotional distress, such as military combat, violent assault, natural disaster, or other life-threatening events.

"Cancer is a perfect storm when it comes to how it affects the brain."

PTSD in cancer survivors may be expressed by reliving the cancer experience in nightmares or flashbacks, continuously thinking about it, avoiding places, events, and people connected to the cancer experience, and/or being continuously overexcited, fearful, irritable, and unable to sleep. To be diagnosed as PTSD, these symptoms must last for at least one month and cause significant problems in the patient’s personal relationships, employment, or other important areas of daily life. Patients who have these symptoms for less than one month may develop PTSD later.

Burke says cancer patients with PTSD may avoid going to health appointments, ignore appropriate self-exams, or refuse to talk about or even say the word “cancer”—reactions that can lead to poor health behaviors, such as alcohol and drug use to numb the person’s emotions, lack of self-care, and emotional distancing.

Burke focuses on four components of therapy for these patients. First, he helps patients work on grieving the losses of cancer, which may be temporary or permanent. “They need to grieve that loss so they can deal with their new normal to redefine themselves,” he says. Next, he encourages survivors to define themselves not by what they can’t do, but by what they can do. Third, the survivors need to normalize the cancer experience by learning to accept that they might not feel great, even if they have survived cancer. Fourth, they must process what has occurred.

“Cancer is a perfect storm when it comes to how it affects the brain,” Burke explains. “The brain has been affected by chemotherapy, radiation, surgeries, cancer itself, and other inflammatory processes. The brain regulates so many functions, including thought, cognition, motivation, energy, and sleep. When there is a brain dysfunction, such as depression or PTSD, it needs to be treated, so that even the sickest patient with cancer can improve their quality of life.”