How to Treat Emotional Distress? Breast Cancer Guidelines 2020

How to Treat Emotional Distress? Breast Cancer Guidelines 2020

You will likely feel emotional distress at least once throughout your journey with cancer.  Such distress can be treated.

There are three types of treatment for emotional distress. Psychosocial options include talk therapy, support groups, and spiritual guidance. Medications treat mental health problems like anxiety. Integrative therapies such as exercise or yoga are available at no or low cost and have tremendous benefits.

We will now explore in detail each of these options, how they work and how effective they are. First, though, let’s make sure we understand what distress is and how to measure it.

What Is Distress?

Distress is social, mental, emotional, or spiritual stress or pain that can affect all aspects of your life. Distress can be the result of being diagnosed with cancer, cancer treatment and its side effects, fear of dying of cancer, the costs of treatment, and the stress on your relationships. Distress can also be the result of concern you have about your roles at work, at home, in your social circles, as a parent, and as a partner. A cancer diagnosis can be especially distressing if you have a history of depression, anxiety, or other mental health problems.

Distress can show up as helplessness, depression, anxiety, difficulty sleeping, questioning your purpose or faith, and frequent thoughts about your mortality.

A Few Examples of Distress Symptoms
A Few Examples of Distress Symptoms

It is normal and expected that you would have feelings of distress. These feelings can affect how well you make decisions and take the best care of yourself, reach out to others, and even do the things you need to do each day, such as take care of things around the house.

For this reason, multiple specialty groups have developed guidelines on how distress should be diagnosed and treated. One such group, the National Comprehensive Cancer Network (NCCN), made guidelines on how to properly address and treat distress in cancer patients. This article will specifically focus on how to treat emotional distress in cancer patients based on the NCCN Guidelines for Distress Management.

Common Situations Causing Distress
Common Situations Causing Distress

Types of Treatment

1. Psychosocial Interventions

Psychosocial interventions are all interventions where counseling or behavior management is used. You may be having trouble adjusting to a diagnosis of cancer, making medical and other decisions, or with conflicts with the people in your life whom you love.

Psychosocial interventions have been studied and shown to help people deal with distress and to improve overall quality of life. Below are five types of psychosocial interventions that you can use to treat your emotional distress.

a) Psychoeducation – When people with specific distress or health conditions learn about their conditions, it is called psychoeducation. Learning about your condition allows you to better cope with it. Psychoeducation can involve one-on-one teaching, group learning, reading materials, and online resources. Your medical team can help you find useful resources.

b) Psychotherapy – Psychotherapy is another term for talk therapy and is facilitated by a trained professional like a psychologist, social worker, trained nurse, or other professional. You can take part in psychotherapy in a one-on-one setting or in a group setting. In talk therapy sessions, your professional may use a technique called cognitive behavioral therapy, which will help you identify and change inaccurate thoughts that contribute to distress.

c) Family and Couples’ Therapy – Although cancer is an individual diagnosis, it is likely that the other people in your life are also affected.. Family members, including partners, children, parents, siblings, as well as your good friends, can share in your distress and have their own distress separate from yours. As you manage your own distress, it can sometimes be hard to “hold” their distress as well. Family and couples’ therapy may be helpful and even more effective than individual therapy. Some data has shown that couple-based therapy improves depression, anxiety, and marriage satisfaction.  Family members, including children, may benefit from getting individual support—this can help take the pressure off you to provide support to them while taking care of yourself.

d) Social Work & Counseling Services – Social work and counseling services should be used if you need practical help or have psychosocial problems that relate to adjusting to cancer. Practical help refers to assistance with activities of daily living such as transportation, food, or housing. Psychosocial problems can directly cause emotional distress for cancer patients and can be feelings of fear, depression, worry, nervousness, and suicidal thoughts or behavior. Psychosocial problems can also be experiences such as family conflicts, social isolation, and poor coping or communication skills.

Social workers can also help facilitate patient and family education, offer counseling and talk therapy services, connect you with support groups, and teach coping strategies. A few examples of coping strategies are finding solutions to difficult problems, identifying and challenging thoughts that are not actually true (for example, that you caused your cancer), managing your emotions, and acting in the most helpful ways to take the best care of yourself. Social workers have a bachelor’s, master’s, or doctorate degree in social work. Oncology social workers are specifically educated and trained to provide specialized care to cancer patients.

e) Spiritual & Chaplaincy Care – As a cancer patient, emotional distress can come from spiritual or religious concerns. Some cancer centers have on-site chaplain services or can refer you to a chaplain in the community. A certified chaplain completed specific courses and training to provide chaplaincy services for grief, guilt, loss of faith, spiritual concerns, and other issues.

Chaplains can help you cope with a cancer diagnosis by providing spiritual counseling, guidance, and comfort through religious reading and prayer. They can also help with concerns about guilt, forgiveness, the afterlife, perceptions of being attacked by evil, religious beliefs conflicting with treatment options, relationships with the sacred, and other spiritual needs.

Religion helps many cancer patients who experience an existential crisis such as searching for the meaning and purpose of life or the meaning of experiencing cancer, making the most of life, being independent, and being treated like a “normal” person. Data suggests that religion helps improve quality of life, depression, anxiety, hope, and self-efficacy.

Many patients also say that prayer is a major help. Your chaplain can pray for or with you, provide rituals for you, contact religious leaders of your faith, communicate with your faith community on your behalf, or connect you with a faith community if you are in need. Data shows that spirituality and religion are associated with better mental health in people with cancer. Engaging in spiritual and religious practices may also improve quality of life for some people.  

2. Medication

You may benefit from medications for treatment of distress. If you have a diagnosis of depression or anxiety or another mental health problem that was part of your life before you were diagnosed with cancer, it is important to work with your entire medical team.

Some of the types of medications that can help with treating distress are described below. This is not a full list, and your medical team, including your primary care doctor and a psychiatrist, may offer other options.

a) Antidepressants Antidepressants are commonly used to treat both depression and anxiety in mental health disorders and have a significant amount of evidence to improve depression and anxiety in cancer patients. Some examples include:

  • Zoloft (sertraline)
  • Celexa (citalopram)
  • Lexapro (escitalopram)
  • Prozac (fluoxetine)
  • Paxil (paroxetine)

It can take several weeks (about 4-8 weeks) for these medications to take effect and to improve depression and anxiety. If you don’t see improvement in your symptoms right away, stick with them, and remember to take them every day. Antidepressants are safe, but just like with any medication, make sure to ask your doctor and pharmacist about common side effects. Some people report an increase in suicidal thoughts; this is rare but an important side effect to tell your doctor about right away. If you want to stop taking an antidepressant that you have been taking regularly, you will feel much better if you decrease the dose slowly. Stopping suddenly can lead to uncomfortable side effects like a “fuzzy” feeling, body pain, dizziness, and other uncomfortable feelings.  If you decide that you want to stop the medication, work with your medical team to make the process of coming off the medication as smooth as possible for you.

b) Benzodiazepines Occasionally, people living with cancer have acute, or sudden, anxiety. Short-term use of anti-anxiety medications can be considered. Benzodiazepines are a common group of medications that can be helpful for short-term use. A few medications in this group include:

  • Xanax (alprazolam)
  • Ativan (lorazepam)
  • Klonopin (clonazepam)
  • Valium (diazepam)

Most doctors avoid giving these medications because of their addictive potential and the fact that your ability to think clearly can be decreased on the benzodiazepines. These medications can also cause physical dependence and addiction and are therefore controlled substances that require increased monitoring and special rules for prescribing and dispensing to patients. When these medications are used long-term, they should not be stopped abruptly. They should be gradually tapered off over time to avoid withdrawal symptoms like agitation, seizures, delirium, and insomnia.

c) Antipsychotics – Rarely, antipsychotics are used in patients with cancer to treat psychosis, fear, agitation, steroid-related mood lability, delirium, and sleep. Psychosis is a condition where patients have trouble distinguishing between what is real and what is not. Mood lability is when your emotions change rapidly and don’t always “fit” the situation. Antipsychotics can also be used to treat anxiety in cancer patients when other medications don’t work. Antipsychotics are usually prescribed with the expertise of a psychiatrist.

3. Other Treatments

a) Exercise – It’s no secret that physical activity has benefits in everyone. If you’ve been diagnosed with cancer,  exercise during and after cancer treatment can improve heart health, balance, the proportion of muscle in your body, and overall quality of life. Depression also gets better in people who have had cancer and in people currently living with cancer. Cancer-related fatigue, which can worsen distress, also improves with exercise. Although more research needs to be done regarding how well exercise can be used to treat mental health in cancer patients, the improvement in overall quality of life is reason enough to increase physical activity.

b) Complementary Medicine – Complementary medicine is defined as non-conventional or non-mainstream medical care. When both complementary and conventional/mainstream medicine are used together, we call this integrative therapy. For example, when yoga therapy (complementary) is used with an antidepressant or counseling services (conventional/mainstream) the combination is called integrative therapy. (Some may find it interesting that yoga, which has been around for thousands of years, is considered non-mainstream and that relatively recent cancer treatment you receive in your doctor’s office is considered mainstream).

Research shows that non-medical therapy is helpful in people with breast cancer with distress. This means that complementary treatment like meditation, yoga, relaxation with imagery, massage, and music therapy combined with mainstream medical therapy improves depression disorders in cancer patients. You may also find that your anxiety decreases with music therapy, meditation, and yoga. Ask your health care team, including the social worker and nurses on your team, what is available for you. If these types of treatment are not available in your doctor’s office, community groups often offer these types of services, often at no cost.

Final Thoughts…

Distress is caused by many factors and can affect many parts of your life including your emotional, mental, social, spiritual, financial, and family life. You are not alone…distress is common among people living with cancer. Let your medical team know if you are having any of the types of distress described in this article. You have options for treatment of your distress as well as the cancer.

Common Problems of Distress that You May Experience
Common Problems of Distress that You May Experience
**you may experience other problems not listed above, as this is not a comprehensive list**

References

  1. Riba MB, Donovan KA, Anderson B, et al. National comprehensive cancer network guidelines distress management. Version 2.2020 From the National Comprehensive Cancer Network; March 2020. https://www.nccn.org/professionals/physician_gls/pdf/distress.pdf. Accessed June 15, 2020.
  2. National Comprehensive Cancer Network (US). NCCN Guidelines for Patients: Distress. Version 1.2017. Fort Washington, PA: NCCN; 2017.