CopingWithDepressionandCancer

SarahRosenbloom,Ph.D.AssistantProfessor

DepartmentofPsychiatry&BehavioralSciencesDirector,SarahRosenbloomPh.D.&Associates

CancerConnectionsMarch3,2018

Commonemotionsaftercancer

Sadnessvs.Depression

SymptomsofDepression

Copingandtreatmentstrategies

Positivechangesaftercancer?

Cancer….???!

• Shock• Overwhelm• Questions• Answers?• Makingchanges• Learninganewlanguage• Rearrangingyourlifeasyoustarttreatment• Newcircumstancesand/orsymptomsmaytakeatollonbodyandmind

TheRollercoaster

EmotionsandCancer

• Youmaybeafraidorworriedabout:- Beinginpainfromcancerortreatment- Feelingsickorlookingdifferent- Takingcareofyourfamily- Payingyourbillsorkeepingyourjob- Dying• Somefearsaboutcancercanbebasedonrumorsormisinformation

FearandWorryCommonFeelings

• Extraworry,inabilitytorelax,feelingtense.Youmaynoticethat:- Yourheartbeatsfaster- Youhaveheadachesormusclepains- Youdon'tfeellikeeating.Oryoueatmore- Youfeelsicktoyourstomachorhavediarrhea- Youfeelshaky,weak,ordizzy- Youhaveatightfeelinginyourthroatandchest- Yousleeptoomuchortoolittle- Youfindithardtoconcentrate

• Stresscankeepyourbodyfromhealingaswellasitshould

StressandAnxiety

• NORMALresponsetoanyseriousillness• Losses- Ofhealth- Oflife/lifestylebeforeillness- Ofcontrol- Ofideasaboutfutureplans• Commonsymptomsinclude- Distraction- Fatigue,lethargy- Tearfulness- Lackofappetite- Usuallyimprovesovertime

SadnessandDepression

StagesofGriefinCancer

Noteveryonemayexperienceallstagesorgothroughtheminaparticularorder:

1. Denial– shock,disbelief;canbeprotective2. Anger– ‘it’snotok’3. Bargaining– ‘Ifonly…’or‘Ipromisetochangeif…’4. Sadnessanddepression5. Acceptance– ofa‘newnormal’

DenialCanbeGoodForYou

“It’salwaysbeenhardformetotellthedifferencebetweendenialandwhatusedtobeknownashope.”

-MichaelChabon,novelist

WhatistheDifference?

• Sadness…aboutsomething- Usuallytriggeredbyanevent- Oftenlessensorgoesawayovertime- Doesnottypicallyaffectmotivationorsatisfaction• Depression…abouteverything-Maynotbetriggeredbyspecificevent- Affectsthinking,emotions,perceptions,behaviors- Pervasiveandchronic- Thingsseemlessenjoyable,interesting,important,orworthwhile-Mayfeellikebeingmoreimpatient,frustratedorirritable

Sadnessvs.Depression

6WaystoTelltheDifference

1. Canyoustillenjoythethingsyoulike?2. Areyouremotionsaboutaspecificeventorthing?3. Areyoueatingandsleeping(somewhat)normally?*4. Doyouexperiencevariationsinyourbadmood?5. Doyouhaveself-criticalthoughts?6. Haveyouhadthoughtsofharmingyourself?

*Withcancer-relatedcaveat

SadnessandDepression

Diagnosis:Depression

Onmostdays:• Adepressedorirritablemood• Alossordecreaseofpleasureorinterestinmostactivities,includingonesthathadbeenenjoyedbefore• Significantchangesinweightorappetite*• Disturbancesinfallingasleeporsleeping toomuch*• Feelingsloweddowninyourmovementsorrestless*• Feelingtired,sluggish,andhavinglowenergy*• Havingfeelingsof worthlessorexcessiveguilt• Experiencingproblemswiththinking,focusing,concentrationortheabilitytomakedecisions*• Havingthoughtsofwantingtodieorharmyourself

Atleast5ofthefollowingpersistingforatleast2weeks:

*Withcancer-relatedcaveat

PrevalenceofDepressioninCancer

• Recentmeta-analysisindicatedratesbetween8-24%(Krebber etal.,2014)• Dependsonhowyoumeasureit:substantiallyhigherwhenself-reportedvs.clinicalinterview• Prevalencemuchhighercomparedwith4%inthegeneralpopulation• HighestratesamongpatientswithGI,brain,gynecologicalandhematologicalcancers- Otherstudiessuggesthigherratesamongthosewithhead/neck,pancreatic,breastandlungcancers(Massie,2004)

• Highestintheacutephaseofthedisease,oftendecreasingafterwards• Higherriskforyoungerpatientsduetolifedisruption,greaterphysicalsymptomburden,andincreasedlikelihoodofdevelopingaggressivedisease(Park,2015)• Genderdifferences?

SomeComponentsofDepression

• Youmayblameyourselfforupsettingthepeopleyoulove

• Worryaboutbeingaburdeninsomeway• Feelingsad/ashamedofnotbeingabletoenjoyothers’positiveevents• Youmayblameyourselfforlifestylechoicesthatyouthinkcouldhaveledtoyourcancer

“WhenIstarttofeelguiltythatIcausedmyillness,Ithinkofhowlittlekidsgetcancer.Thatmakesmerealizethatcancercanjust

happen.Itisn'tmyfault.”-Becky

Guilt

• Youmaybelessabletotakepartinthehobbiesandactivitiesyouusedtoenjoy• Youmayfeelthatnooneunderstandswhatyou’regoingthrough• Youmayfeelisolatedfromothers• Othersmayminimizeyoursituationorhowyoufeel• Youmaynotknowanyoneelsewhohasgonethroughwhatyouaregoingthrough• Youmayfeellovedonesmeanwell,butdonotknowwhattosayorhowtoacttowardyou

Loneliness

• It'snormaltoask,"Whyme?"andbeangry• Youmayalsofeelangerorresentmenttowards- Healthcareproviders- Healthyfriends- Lovedones- God• Angeroftencomesfromfeelingsthatarehardertoshow:- Fear,anxiety- Helplessness- Depression

• Angercanbehelpfulinthatitmaymotivateyoutotakeaction

Anger

WhenDepressionorAnxietyGetsintheWay

- Feelingsofsadnessthatdon'tgoaway- Feelingemotionallynumb- Feelingnervousorshaky- Havingasenseofguiltorfeelingunworthy- Feelingshort-tempered,moody- Feelinghelplessorhopeless,asiflifehasnomeaning- Havingahardtimeconcentrating,feelingscatterbrained- Cryingforlongperiodsoftimeormanytimeseachday- Focusingonworriesandproblems- Nointerestinthehobbiesandactivitiesyouusedtoenjoy- Findingithardtoenjoyeverydaythings,suchasbeingwithfamilyandfriends- Thinkingabouthurtingyourselforendingyourlife

EmotionalSigns:

WhenDepressionorAnxietyGetsintheWay

• Unintendedweightgainorlossnotduetoillnessortreatment• Sleepproblems,suchasnotbeingabletosleep,havingnightmares,orsleepingtoomuch• Racingheart,drymouth,increasedperspiration,upsetstomach,diarrhea• Changesinenergylevel• Fatiguethatdoesn'tgoaway• Headaches,otherachesandpains

PhysicalSigns:

TheBigQuestion:CanDepressionHurtMe?

• Severalrecentstudieshavelinkeddepressionandincreasedmortalityfromcancer• How?- Behavioral:Lessadherencetotreatment?Missedappts?- Biological:Stresshormoneandinflammatorydysregulationresponse?

• But:- Correlation≠causation- Lackofdataondepressionandcancerhistory,cancersymptomsandfunctionalstatus,whetherornotpatientsweretreatedfordepression

- Couldassociationsreflecteffectsofcanceronmood?

YesandNo.Butitshouldbetreated.

Well-Meaningbut…

CopingStrategies

ManageInformationFlow• Most– butnotall– peoplefeellessafraidanddepressedwhentheyknowmoreaboutwhattoexpect• Studiessuggestthatthosewhoarewell-informedaremorelikelytofollowtheirtreatmentplansandrecoverfromcancermorequicklythanthosewhoarenot• HowmuchDOyouwanttoknowaboutyourcancer?- All/Nothing/Somewhereinbetween- Thinkaboutwhichapproachworksbestforyouandletyourhealthcareteamknowwhatyou'dprefer

BUTALSO:• Takeabreakfromcancerinfo-seeking

AnticipatePossiblePhysicalChanges

• Askyourdoctorwhatchangesyoushouldanticipate- Ifdrugswillcausehairloss,advicefromexpertsaboutclothing,makeup,wigsandhairpiecesmayhelpyoufeelmorecomfortable

- Insuranceoftenhelpspayforwigs,prosthesesandotheradaptivedevices.

• Considerhowtreatmentwillimpactyourdailyactivities.Askyourdoctorwhetheryoucanexpecttocontinueyournormalroutine.Youmayneedtospendtimeinthehospitalorhavefrequentmedicalappointments• Ifyourtreatmentwillrequirealeaveofabsencefromyournormalduties,makearrangementsforthis

MaintainaHealthyLifestyle

• Chooseahealthydietconsistingofavarietyoffoods• Getadequaterestwithgoodsleephygiene• Exercise- Recentdatasuggestthatpeoplewhomaintainsomephysicalexerciseduringtreatmentnotonlycopebetterbutmayalsolivelonger

- Naturalanti-depressant• Limitalcoholandcaffeine• Participateinenjoyableactivities

There’snotimelikethepresent!

TrytoMaintainYourNormalLife

• Regularroutinesandhabitsareimportanttomaintainingidentityandsenseofself• Takeonedayatatime.It'seasytooverlookthissimplestrategyduringstressfultimes• Trytokeepincontactwithothersinyourlife• Whenthefutureisuncertain,regularresponsibilities,organizingandplanningmaysuddenlyseemoverwhelming– dowhatyoucan

(Asmuchaspossible)

LetFriendsandFamilyHelpYou

• Oftenfriendsandfamilycanrunerrands,providetransportation,preparemealsandhelpyouwithhouseholdchores- Carecalendar.org- Lotsahelpinghands.com• Learntoaccepttheirhelpevenifit’samajorchange• Preserveenergyfordoingthingsyouenjoy• Timewithfamilyandfriendscanbeawelcomedistraction• Youmayprefersomepeople’scompanyoverothersatthistime

ExpressHowYouFeel

• Manypeoplefindwhentheyexpressstrongfeelingstheyaremoreabletoletgoofthem• Lookforemotionalsupportindifferentways- Friendsorfamily- Othercancersurvivors,supportgroup

- Therapist- Spiritualleader• Thinkingaboutorwritingfeelingsdownifyouprefernottodiscussyourcancerwithotherpeople

• Loremipsumdolorsitamet,consectetur adipiscing elit.Mauris duimauris.• Atmipharetra,pulvinar pellentesquedolor.Aenean dignissim risus necneque tincidunt iaculis innec neque.

29

Don’tTrytoBeUpbeatifYou’reNot

WhoCanITalkToAboutCancer?

• SupportiveOncologyProgramatRHLCCC- SupportGroupsforpatientsandcaregivers- IndividualServices• Gilda’sClubofChicago– freeactivities,groupsandprogramsdesignedtoimprovesupportandcoping• Othercancersurvivorscangiveyouinsightintoyourspecificdiagnosisortreatment:- Imerman’s Angels:http://imermanangels.org/• Afriendorfamilymemberwhohashadcancer• AmericanCancerSociety’sCancerSurvivorsNetwork:https://csn.cancer.org/• CancerCarenationalonlinenetworkforemotional,physicalandfinancialresources:http://www.cancercare.org/

WhatCanIControl?

• Beinginvolvedinhealthcare• Makingpositivechangesinlifestyle• Startnew(oranew)activitiesandhobbiesthatyoucandoanywherelikeart,photography,reading,musicorcrafts.Coloringbooks!• Organizepartsoflifethatyoucan• Setadailyschedule• Reviewyourgoalsandpriorities,andfindtimefortheactivitiesthataremostimportanttoyouandgiveyouthemostmeaning

“Ihavegooddaysandbaddays.ButItrytolettherebemoregoodonesthanbad,andfocusonthingsinmylifethatIcancontrol.Itryto

enjoyfamily,friends,andthelittlethingsinlife.”-Louise

SpiritualHealing

OtherComplementaryTreatmentsforDepression

• Exercise– betterthanalmosteverything• Omega3/fishoilsupplements- atleast1000IU- Inusinganysupplement,letyourmedicalteamknow• VitaminD• Lighttherapy- 10,000lux- 30minsperday,ideallyinmorning

Medication?

StrengthsandSkillsYouMightForgetYouHave

Whathelpedyouthroughroughtimesbeforeyourcancerdiagnosisislikelytohelpeaseyourworriesnow,whetherthatis:

• Anyoftheabove• Aclosefriend• Alovedone• Atherapist• Areligiousleader• Afavorite,meaningfulactivitythatrechargesyou

Turntothesecomfortsnow,aswellasbeopentotryingnewones

DevelopYourOwnCopingStrategyJustaseachperson'scancertreatmentisindividualized,soisthecopingstrategyyouuse

EmotionsandCancer

HopeandGratitude

• Millionsofpeoplewhohavehadcancerarealivetoday• Yourchancesoflivingwithcancer—andlivingbeyondit—arebetternowthantheyhaveeverbeenbefore• Peoplewithcancercanleadveryactivelives,evenduringtreatment

• Somepeopleseetheircancerasa"wake-upcall.• Realizingtheimportanceofenjoyinglittlethingsinlife• Renewedmotivationtogoplacesordothings• Spendingmoretimewithfriendsandfamily• Mendingbrokenrelationships

Post-TraumaticGrowth

• Positivepsychologicalchangeexperiencedasaresultofadversityorchallengeinordertorisetoahigherleveloffunctioning• ResiliencePLUS- Atraumaticeventcanchallengebeliefsandpsychologicalwell-being…personalgrowthbeyondbouncingback

• Examples:- greaterappreciationoflife- changedsenseofpriorities- moreintimaterelationships- greatersenseofpersonalstrength- Spiritualdevelopment- Enhancedsenseofpurposeormeaning

AKAFindingBenefits

EnhancingOpportunitiesforGrowth

• Reduceanxiety• Reflectonyourexperience- Journaling ortalkingwithafriendorfamilymemberarewaystoprocessandmakesenseofatraumaticevent

• Restoreasenseofsafety• Connectwithothers- Talkingwithagroupofpeoplewhohavehadsimilarpathscanhelpyoulookatyourcancerjourneyinanewway

• Createa‘post-traumalifevision’- Thinkthroughwhatyouhavelearnedfromyourexperience.Thenconsiderputtingaplaninplaceforlivingmorefully

FindWaystoHelpYourselfRelaxandRecharge

•Whateveractivityhelpsyouunwind,youshouldtaketimetodoit•Mayneedmodifications:suchasRunning->Yoga•Meditation,relaxationorimageryexercisesmayhelp-Mayrequirepractice- Classes,CDs,online- Examplesatendofthispresentation

(OldorNew)

AdditionalResources

• Diagnosis:Cancer:YourGuidetotheFirstMonthsofHealthySurvivorship(RevisedEdition)(Harpham,2003)• AfterCancer:AGuidetoYourNewLife(Harpham,1995)• TheHumanSideofCancer:LivingwithHope,CopingwithUncertainty(Holland&Lewis,2001)• TheAnatomyofHope:HowPeoplePrevailintheFaceofIllness(Groopman,2005)• WhenLifeBecomesPrecious:TheEssentialGuideforPatients,LovedOnes,andFriendsofThoseFacingSeriousIllnesses(Babcock,1997)• HowtoHelpChildrenThroughaParent’sSeriousIllness:Supportive,PracticalAdvicefromaLeadingChildLifeSpecialist(McCue&Bonn,2011)• ThePosttraumaticGrowthWorkbook:ComingThroughTraumaWiser,Stronger,andMoreResilient (Tedeschi &Moore,coming12/1/16)

KeyFacts

Questions?

ThankYou

S-rosenbloom@northwestern.eduwww.sarahrosenbloomphd.com

GetReady,GetSet,RELAX

• Foreachexercise,findaquietplacewhereyoucanrestundisturbed.Letothersknowyouneedtimeforyourself.Makethesettingpeacefulforyou.Forexample,dimthelightsandfindacomfortablechairorcouch.• Youmayfindthatyourmindwanders,whichisnormal.Whenyounoticeyourselfthinkingofsomethingelse,gentlydirectyourattentionbacktoyourbody.Besuretomaintainyourdeepbreathing.• Somepeopleliketolistentoslow,calmingmusicwhilepracticingtheseexercises.

GettingStarted

NationalCancerInstitutehttps://www.cancer.gov

Posted: February29,2016

BreathingandMuscleTensing

• Getintoacomfortableposition.Closeyoureyesandclearyourmindofdistractions.Ifyou’relyingdown,youmaywanttoputasmallpillowunderyourneckandknees.• Breathedeeply,ataslowandrelaxingpace.Concentrateonbreathingdeeplyandslowly,raisingyourbellywitheachbreath,ratherthanjustyourchest.• Next,gothrougheachofyourmajormusclegroups,tensing(squeezing)themforafewsecondsandthenlettinggo.Startatthetopofyourheadandworkyourwaydown.Tenseandrelaxyourfaceandjaws,thenshouldersandarms.• Continuetensingandrelaxingeachmusclegroupasyougodown(chest,lowerback,buttocks,legs),endingwithyourfeet.Focuscompletelyonreleasingallthetensionfromyourmusclesandnoticethedifferencesyoufeelwhentheyarerelaxed.

NationalCancerInstitutehttps://www.cancer.gov

Posted: February29,2016

SlowRhythmicBreathing

• Stareatanobjectorshutyoureyesandthinkofapeacefulscene.Takeaslow,deepbreath.• Asyoubreathein,tenseyourmuscles.Asyoubreatheout,relaxyourmusclesandfeelthetensionleaving.• Remainrelaxedandbeginbreathingslowlyandcomfortably,takingabout9-12breathsaminute.Tomaintainaslow,evenrhythm,youcansilentlysaytoyourself,“In,one,two.Out,one,two."• Ifyoueverfeeloutofbreath,takeadeepbreathandcontinuetheslowbreathing.• Eachtimeyoubreatheout,feelyourselfrelaxingandgoinglimp.Continuetheslow,rhythmicbreathingforupto10minutes.• Toendthesession,countsilentlyandslowlyfromonetothree.

NationalCancerInstitutehttps://www.cancer.gov

Posted: February29,2016

Imagery

• Usuallyworksbestwithyoureyesclosed.• Tobegin,createanimageinyourmind.Youmaywanttothinkofaplaceoractivitythatmadeyouhappyinthepast.Explorethisplaceoractivity.Noticehowcalmyoufeel.• Breatheslowlyanddeeply.Asyoubreathein,saysilentlyandslowlytoyourself,“In,one,two,”andasyoubreatheout,say“Out,one,two.”• Ifyouhavepain,youmayimagineyourselfasapersonwithoutpain.Inyourimage,youcancutthewiresthatsendpainsignalsfromonepartofyourbodytoanother.Oryoumayimaginehealingenergyformingandtakingshapeinanypartofyourbody.• Whenyou’reready,imaginethattheairyoubreatheinblowsthisenergytotheareawhereyoufeelpain.Oncethere,theenergyhealsandrelaxesyou.• Asyoubreatheout,imaginetheairblowingtheenergyawayfromyourbody.Asitfloatsaway,allofyourpaingoeswithit.• Repeatthelasttwostepseachtimeyoubreatheinandout.