A few recollections of cancer survivors in their journey of dealing with their mental health issues are as follows:
"I was not only mentally spent but also physically exhausted. To me, the weight of cancer was insurmountable and inescapable. It was an invisible world that I had to hold up or risk never coming through the other side of this diagnosis."
"The thought of the thing inside my thyroid kept me up at night. I would lie there and stare up at the ceiling, too tired to function and yet unable to rest."
"Everything was too large to tackle after finding out I had cancer. I was fearful of everything. Everyone was out to get me in one way or another, and my paranoia turned into a daily struggle."
"All I could think of was this: If the universe gave me cancer, what is the rest of the world capable of doing to me?"
Cancer is the second leading cause of death globally and profoundly impacts individuals, families, health care providers, and society. Advancements in medical treatment and increased awareness of screening guidelines have substantially increased the number of people living with cancer, with two-thirds of those diagnosed predicted to live beyond five years. These statistics have brought cancer treatment and long-term management to the forefront of the health care plan.
As the number of individuals living with cancer grows and this illness becomes more akin to a chronic disease that requires ongoing management, the importance of effective identification and treatment of distress becomes essential. A critical component of identifying these chronic illnesses is inculcating a view that encompasses mental health.
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Cancer patients/survivors experience depression and anxiety usually after most of the treatment is completed or in the receding stages. "Individuals have talked about how they have experienced a sense of separation from their peers/ family members and the general population. This differential experience along with managing a strict schedule of medication and healthcare limits the individual's ability to live a full and productive life," says Alpika Kumar, counselling psychologist at the New Delhi-based Karma Center for Counselling & Wellbeing. "There comes a grave sense of loss of control over their health, and with that comes grief of having to miss so many years of life that could have been lived, joyfully, if it wasn't for cancer," she adds.
A central aspect of individuals' ability to cope with the transition from treatment to survivorship can be the coping skills they bring to the situation. Coping self-efficacy, or confidence in dealing with cancer, has been associated with many cancer-related outcomes, including better disease adjustment and management. In addition, experts explain the linkage between mental health and cancer by highlighting mental well-being's role in cancer treatment.
Understanding the linkage
Cancer has become the disease of the body and mind with questions of "why me", depression, anxiety and adjustment issues. Fear is the most common response to cancer diagnosis, and this includes fear due to lack of funds for treatment, fear of treatment, fear of side effects, etc.
Dr Keshav Sharma, lead psycho-oncologist and grief therapist, Fortis Healthcare, Delhi, says that pre-existing psychiatric comorbidity, lack of support system and advanced-stage cancer can lead to issues and concerns related to uncertainty. "That leads to excessive worries related to the future. Every stage of cancer diagnosis comes up with psychological issues which vary in intensity and degree," she says.
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Vikram Kirtikar, a senior psychologist & outreach associate of the Mumbai-based Mpower – The Foundation, works closely with cancer patients and their families. He affirms that there has always been a link between physical health and mental health. "It is known that both complement and support each other. So when one or both get affected by illness, the impact is quite evident," he states. He says that cancer not only affects one's physical health but can also have an impact on the emotional health of a person. "A person can be diagnosed with cancer before a mental health concern, or a mental health concern can be present before the diagnosis of cancer," he adds.
A usual response to diagnosis is denial, shock, and the condition is overwhelming to handle. As the person experiences physical symptoms, it also affects one's emotional health.
Hirak Patel, counselling psychologist, Department of Mental health and Behavioural Sciences, Fortis Hospitals, Mumbai, says that the person can experience waves of intense emotions: sadness, anxiety, worry-- about the treatment and the future. "There is also fear of death, fear of treatment, fear of pain and suffering that makes the person distressed. There are questions that the people have towards the condition which leads them to think more about the situation and feel more anxious, usually developing a negative perspective towards the condition," she elaborates.
The problem of shared symptoms
It might often happen for someone with cancer that their mental health issues might go undiagnosed. Cancer and mental illness-- like depression and anxiety-- have shared symptoms such as sleeplessness, fatigue, and decreased appetite. It makes it difficult for health care providers to identify the patients' mental health conditions. Moreover, having a mental health condition can make cancer worse, as someone with depression is less likely to stick to treatment plans and go through preventive screening.
However, Patel offers a solution wherein the facility can have regular mental health screenings in oncology settings. "Along with advanced treatment procedures, psycho-oncology is now an important branch of the oncology treatment," she mentions. The most apparent and expected response to a cancer diagnosis is sadness, grief, fear, anger etc. "If a patient's concerns are addressed, and psychosocial support is provided from the onset of the diagnosis and treatment, they feel supported, hence reducing the confusion and fear. The ultimate goal is to work towards improving the quality of life of the patients and their caregivers," stresses Sharma. From time to time, psychological distress assessment helps with the process of identifying their needs as well.
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"The sudden nature of the news and the meaning associated with the news by the person can create distress. This processing determines the impact on mental health. The distress if left unaddressed can lead to a mental health concern," reveals Kirtikar. "A presence of a mental illness like depression or anxiety can make this news seem even more distressful, as there is an influence of the view created by the mental illness. For example, the illness depression creates a negative thought process about the self and a hopeless view of the future. This thought process and view can influence how the news of a cancer diagnosis may be processed in mind," he furthers.
Symptoms like fatigue, lack of sleep and decreased appetite are observed in a person with cancer and depression and anxiety. Unfortunately, as the complete focus is on cancer treatment, the treatment of mental illness can get ignored entirely. To avoid this from happening, regular mental health screening of cancer patients can be a part of the overall treatment protocol. Mental health professionals can administer objective tools like self-reporting tests, screening tools and assessments.
The benefits of group therapy
It requires a team to meet the psychological and educational needs of a cancer patient. A structured educational and psychological support system in group therapy can help meet the immediate needs of a newly diagnosed patient. Speaking about the benefits of group therapy, Patel says that the environment in group therapy provides patients with mutual support and an educational experience, allowing them to realise they are not alone in their crisis. "Group therapy gives a chance for people to exchange personal experiences and thoughts, coping mechanisms, or firsthand information about diseases or treatments. It also might be able to bridge the gap between medical treatment and emotional assistance and serve as a way for interdisciplinary team members to be aware of their patients' most pressing concerns," she outlines. Kumar adds that group therapy helps the patients and family members explain their unique journey to each other and make sense of it better. At the same time, it helps them draw strength from the uniqueness of other patients' narratives. "The therapist acts as a facilitator rather than the healer."
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Dr Anil Heroor, Director, Advanced OncoSurgery Unit, Fortis Hospitals, Mumbai, throws light on how group therapy can be helpful by saying, "Group therapy sessions, where we have patient support groups and, the psychologist, are beneficial. These sessions help patients cope with their illness, especially early on in the disease. It makes them more confident and what I have seen is that they face the treatments much better after speaking to other patients. I think we must also encourage patients to counsel other patients. This has to be included in the protocol of all cancer patients. I also feel there has to be a psychological counsellor or a life counsellor as a part of the hospital unit for the patients to discuss the anxieties of their future life and the financial problems. "
The role of counselling in cancer treatment
Psychotherapy is very beneficial if we are looking at the mental health impact of cancer survivors. Since after diagnosis, most of the patient's time and energy goes in action mode where they are focused on the medical treatment of the physical body, processing what has really happened usually happens after this. Of course, this can look very different for every individual; there is no one common mental health problem. "Science tells us that the reaction is heavily based on the patients' socio-economic background, their age, their gender, their marital status, other comorbidities along with cancer and their overarching perspective on mental health are factors that can influence a person's decision to avail mental health services," mentions Kumar.
Both Kirtikar and Sharma state that not all people diagnosed with cancer, receiving cancer treatment, or surviving require psychotherapy or get diagnosed with any mental health issues. However, they clarify that most of them can experience mild to severe levels of psychological distress. "Cancer diagnosis does not just affect an individual but their entire ecosystem including their families, friends do get affected by it equally hence they are also experiencing some amount of psychological distress," Sharma explains.
Providing psychosocial support services for individuals with cancer is recognised as an essential component of quality care. Some level of psychosocial distress is normal after a diagnosis of cancer, given the nature of the disease. "It has been found that people with depression might have worse cancer-related outcomes. They might be less likely to follow treatment plans or take prevention screens. For example, they may be less likely to exercise, more likely to drink too much alcohol or miss therapy appointments," she further adds. Other studies show that those dealing with severe mental illness, dementia and substance use are more likely to have lower chances of survival after a cancer diagnosis. There is good research and study that suggest that actively seeking therapy while the treatment is ongoing is a good way to deal with those unwarranted stress and emotions.
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Kumar goes on to detail how therapy can benefit a cancer patient by saying, "In therapy, the patient can process their feelings, explore ways to share their diagnosis with friends and family, and discuss concerns they have about the ways cancer might change their collective lives. And it has been observed that through this sharing and catharsis, which is usually a part of group sessions. So during the process itself, the patients feel a little less isolated and withdrawn and more heard as well as validated."
Heroor says that in his overall experience, he has observed that the patients who are happy, confident, and optimistic generally do better than the patients who are depressed. "A positive attitude is very important in patients for cancer treatment. Surrounding yourself with positive people and positive thinking helps the patients with the fear and uncertainty of the situation."
