Mood Anxiety and Depression

Low mood, anxiety and depression are remarkably common, with the WHO recently estimating that up to a third of populations in Western societies suffer from one of these conditions at any one time.

Mood dysfunction is particularly common after diagnosis of a chronic disease such as cancer. Sometimes there are no obvious causes, but medical complications such as steroid agitation, allergy to drugs and withdrawal from sedatives can all directly contribute to anxiety. Anxiety is also 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. Treatments that put women into menopause or reduce testosterone in men such as after chemotherapy, surgery or, more typically, hormone therapy, are known to worsen mood and trigger depression. Unless lower testosterone levels are needed, as is the case when treating prostate cancer, testosterone replacement therapy can be effective at improving mood and motivation in men. In postmenopausal women with breast cancer, Aromatase inhibitors can lower mood, although 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.

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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 refuse to take in more energy. This is referred to as insulin resistance and eventually leads to diabetes (type‑2).

Research from Scandinavia has revealed a clear association between elevated HbA1c  (a three-month average of your blood sugar levels) and insulin levels with an increased risk of depression. Another study has demonstrated that young men with insulin resistance have been found to be  three times more likely to suffer from severe depression, while it has also been observed that antidepressant medications do not alter this association because these 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 when seeking to decrease your risk of 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, and these are associated with depression. The current medical literature outlines that if you are overweight or obese, you likely have low-grade systemic inflammation. A diet rich in animal protein, healthy fats and antioxidants will help reduce inflammation and limit the damaging effects of reactive oxygen species (ROS) produced during the inflammatory response. Coffee, dark chocolate and 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, while a poor omega‑3 to omega‑6 fats ratio is also associated with a chronic stress state and an increased risk of depression – tips to reduce chronic inflammation.

3. Gut Dysfunction & Dysbiosis

The gut microbiota — commonly referred to as the microbiome — plays a key role in your mental health due to its constant communication with the brain via the vagus nerve. Key neurotransmitters targeted by antidepressants – serotonin and dopamine – which most people assume are solely developed in the brain, are actually produced in greater concentrations in the gut.

This gut-brain axis is highlighted by research showing how poor gut health leads to poor zonulin function. If Zonulin (a key molecule that regulates gut permeability) is impaired, symptoms of a leaky gut can develop, leading to a pro-inflammatory environment which creates the cytokine storm that contributes to low mood and depression.

Probiotic healthy bacteria has been the subject of a great deal of attention recently as more evidence emerges of a link between gut health and a healthy mind. Studies involving mice conducted by the Alimentary Pharmabiotic Centre at the University of Cork have highlighted how 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, as well as altered expression of receptors for the neurotransmitter GABA in the brain. In humans, a study from The University of California demonstrated how healthy women consuming probiotic yoghurt were reported to have improved brain function and less environmentally induced markers of stress.

4. Food intolerances and leaky gut syndrome

As we get older, developing an intolerance to gluten found in wheat and other grains becomes increasingly common, while our ability to metabolise lactose in milk also falls. Both of these changes can cause gut inflammation and irritable bowel symptoms 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. Repeated 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, e.g. ibuprofen and naproxen) you’ll be much more prone to leaky gut and chronic inflammation. A dietary approach focused on traditional foods — animal protein, healthy fats, vegetables and unprocessed carbohydrates — will help keep blood sugar levels balanced and support a healthy gut microbiota, keeping systemic inflammation and low mood at bay – tips to improve gut health.

5. Exercise and avoiding a sedentary lifestyle

Exercise has been shown to be particularly effective at improving mood and reducing anxiety, especially if there is a social component to the activity. A recent meta-analysis of 92 studies analysing more than 4,310 people showed that light to moderate exercise significantly reduced the incidence of depression. Another recent meta-analysis of RCTs involving women with breast cancer reported a 15% reduction in depression scores following group or supervised exercise classes. A further study involving 1,966 patients with colorectal cancer highlighted how achieving at least 150 minutes of physical activity per week led to better mood scores and an 18% higher quality of life scores than those who reported no physical activity.

In terms of anxiety alone, analysis of data from 40 studies involving 3,000 participants reported that sessions of at least 30 minutes of exercise three times a week led to a 20% reduction in anxiety symptoms. The effect was greater among patients who were sedentary before the start of the intervention, and exercise proved effective at reducing anxiety in subjects suffering from a broad range of health problems including cancer, heart disease and fibromyalgia.  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 and gets people out of the house and socialising and interacting with other people – read more about exercise.

6. Mindfulness-based stress reduction (MBSR)

MBSR done properly elicits a relaxation response (RR) that is characterised by decreased oxygen consumption, increased exhaled nitric oxide and reduced psychological distress. MBSR therapy was investigated in a controlled study involving 84 women with breast cancer. Subjects randomised to take part in a 6-week MBSR programme reported significantly improved 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 MBSR intervention, a short 8-week MBSR intervention, long term MBSR interventions. Both interventions led to 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.

Yoga was investigated in a small RCT involving women with breast cancer. The study demonstrated a significant decrease in anxiety states and improvements in QoL following surgery among participants randomised to be part of a regular yoga class.

Massage, especially when combined with exercises such as yoga or Pilates, is an excellent remedy for anxiety and the muscle tension associated with it. Hands-on complementary therapies such as reflexology and acupuncture have also been shown to improve anxiety.

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 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 having another cigarette. This leads to an escalating spiral of increased cigarette dependence, followed by more anxiety. Although a small glass of wine or beer with friends can lead to better social interaction, excess alcohol and illegal recreational drugs inevitably lead to problems. When the pleasant effect of these substances wears off people often become irritable, experience a significant lowering of mood, and suffer from withdrawal anxiety and, in some cases, depression. It is no coincidence that suicide rates are considerably higher among heavy smokers, alcoholics 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-rich plants such as avocado (read more about how to increase healthy fats and reduce unhealthy fats ). While too much meat intake can increase the risk of chronic inflammation, a recent study highlighted how vegans have a higher risk of depression, so consuming fish or meat once or twice a week is recommended. Polyphenols are also effective at improving mood as they have direct anti-inflammatory, sugar lowering and gut-improving properties – tips on improving polyphenol intake.

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 in order to pinpoint any deficiencies they might have.

9. Vitamin D and sunlight exposure

Vitamin D has been widely reported to be an important factor in preventing 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. Effective detection and treatment of inadequate vitamin D levels may be an easy and cost-effective therapy which will improve patients’ long-term health outcomes as well as their quality of life – tips to increase vitamin D levels.

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 published in 2019 showed that an intervention which helped weight loss also improved mood and reduced incidence of depression. We also know that being overweight is associated with poorer gut health – tips to maintain a healthy weight.

REFERENCES

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:JAMA. 2019;321(9):869-879. doi:10.1001/jama.2019.0557