Coping with Psychological Stress and Depression among the Terminal Ill Patients in India
Depression and stress are the two universal factors that pre-occupied the terminally ill patient in the most degraded way. Though the concept of psychological depressive symptoms affecting the terminally ill patient is not a new idea, yet still stood as an unsolved mystery in many clinical practices. It is the fact that treatment of terminally ill diagnosis is always accompanied with several physical stressors and psychological stressor symptoms outcomes like toxins, mood disorder, trauma and low self-esteem. The stress and depressive symptoms resulted in weakening the patient’s physical body that increases the tumor metastasis rate. The outcomes of the stress and depressive symptoms hugely depend on the individual experience with the deadly disease and on how well he/she copes with psycho-emotional issues in the course of illness. The psychological cognitive assessment is equally important alongside the physical pain symptom in terminal diagnosis. On the other hand, failing to acknowledge the stressors and depressive symptoms will decrease the patient life expectancy and also increase the rate of suicidal activities.
Objective: To study on the effect of biological stressor on various parts of immunological function and associated with cancer will be to investigate in transverse and longitudinal prospective approach.
Methodology: The proposed study will involve descriptive and analytical research with qualitative method basing on the existing documents and literatures.
Results: The psychological depression and stress sometime fail to acknowledge in the clinical practices that resulted in effecting patient’s physical health stability and increase the rate of disability. Depression has no age bar, in which the level of depression is higher in women with terminal illness than her male counterpart. The psychological approach to terminal care with family and loved ones supporting the patient to face the existential challenges is visible as the core coping mechanism that deliver quality of life and wellbeing in clinical practices.
Keywords: Stress, Depression, Stressors, Terminal diagnosis
Majority of the cancer patients developed the highest level of depression through their traumatic and stressful events than any other ill diagnosis. The risk behind the depressive stressors is visible in worsening patient physical pain symptoms and makes the tumor growth into its advance stage in the fastest ways. Understanding the types of tumor involves in patient terminal experience will provides the needed psychological assessment in the most effective ways. However, in a countrylike India depression and its stressors are considered as symptoms not to be treated in its clinical practices and leaving the terminal patients experiencing a living hell on earth with those unwanted stressors activities. It is not only the disease that disturbs the patient peaceful environment, but it’s the stress and depressive symptoms that destroyed patient hope and the will to live. The immediate need is to assess the patient in the way that he/she can gain the ability to deal and adjust with those stressor events in their terminal experience. Understanding the patient stress and depression will give better ways to understand the Inter-coexistence between human behavior and the cognitive process with the stressors in terminal diagnosis. Acknowledging and addressing the patient psychological stress and depression will not only deliver quality of life, but also will enhance the survival rate and decrease the cancer metastasis growth. Since it’s the emotional suffering that hugely affected the individual lifestyle, it is essential for the interventions of the psychological approach to terminal care in the clinical practices, not only for the patient but also for the family and the clinicians.
Stress and depression in terminal ill experience
No doubt that the advance of medical sciences in clinical practices meets and attends the extensive needs of the cancer patient in the most effective ways. However, terminally ill diagnosis is not limited within the medical technological realm; it requires the assessment of patient psychological depressive stressors through its whole person treatment. Cancer is a symptom that affects every aspects of the individual life through its stressors that needs a special consideration to produce quality of life and wellbeing of the whole in any clinical practices. Being with cancer is a stressor that pre-occupied the patient with several traumatic experiences like grief, disbelief, loss of appetite and anxiety, which are the underlying threat to health and quality of life . Among all the factors death anxiety is the main contributing factor affecting the patient’s immune system, unhealthy relationship, loss of sense over self-esteem and poor decision making towards treatment plan and policy. It is the psychological stress and depression that are associated with the initial stage of cancer and during its metastasis, which hugely decrease the patient quality of life and wellbeing. Stress in its nature of existence is an adaptive reaction in cancer metastasis that usually produces physical, mental, and behavioral changes in patient terminal experience. It is a psychological non-specific reaction towards the external and internal demands of life situations beyond the normal human ability to deal with and that kills the brain cells. Comparatively stress is visible as the most common experience among the terminally ill patients with long term psychological distressed . In one of the latest findings depression and stress are the two common unwanted experience among the cancer patients in India (n=320; 72.5%) . Depression is found higher in the age group of 18-40 among the women with breast cancer patients in India (n=270; 96.7%) . Depression on the other hand is more than just a feeling of worthlessness or mood disorders; it is a symptom that is linked with human brain chemicals of serotonin and norepinephrine, which causes several pains like joint and back pain with sleep disorder and can even leads to depressive episode. In the WHO latest report, depression is accounted for patient adjusted with physical disability, mental and behavior disorder to patient of all ages .
Depression and stress are the two most psychological disorders among the terminally ill patients in India. It decreases the patient health stability, heightened self-depreciation and reduces energy and is different from grief. The underlying features of depression that the terminally ill patients usually experience include bipolar disorder, clinical depressive disorder, persistent depressive disorder, and the seasonal affective disorder. The amount of depression in terminally ill experience varies from one patient to another, in which women with terminally ill experience higher level of depression than her male counterpart . In another latest study among the cancer patients in India the depression rate ranges from 4.4% to 89.9%, with additional dimension of emotional distress. The rate of depression increases as per the stage of the cancer metastasis . on the other hand, lack of awareness, ignorance, social stigma, and discriminations becomes the underlying factors for worsening the patient mental health conditions. Depression has no age bar and is hugely responsible for suicidal activities, in which India is considered to be the most depressed country in the world. Some of the most depressive symptoms are loss of appetite, loss of self-esteem, energy, concentration, and slow in cognitive process related.
The genetic and biological factor plays an important role in patient experiencing depression and stress. Certain genes increase the risk developing a mental illness, depending on one’s life situation may trigger it like abuse or trauma (life experiences). While, some mental health issue arises through the parent environmental exposures resulted in the child’s mental disorder. The exposure to environmental stressors, inflammatory conditions, toxins, alcohol, drugs while in the womb can sometime makes the child suffering from mental illness. Brain chemistry is also another cause for mental health problem; when the neurotransmitters that carry signals from one part to the other parts of the brain and body impaired, the function of nerve receptors and nerve systems change dramatically leading to depression and other emotional disorders . Cancer/terminal illness is a unique experience that has both the disease and the situational challenges that produces uncertainty over life and huge psychological effects that disturb the individual nature of existence in the most rigorous way. It is important to acknowledge the patient adaptive capacity over his/her environmental challenges and to understand how the individual response to the stressor’s events in terminal experience. Knowing the level of patient sense of sensitivity towards the stressors event is also important in developing the coping strategies in the most effective way . Looking at the current condition of India the depressive stressors that puts the individual’s life into miserable condition and severe problems in daily life and relationships remain unconcerned. Moreover, the signs and symptoms of depression can be varying from one person to another depending on the mental or psychological state of the individual. In general, mental health symptoms can affects emotions, behaviors and the cognitive process.
The psychological stress, anxiety and depression are the most common negative outcomes in any terminal experiences, which require special consideration in attending the patient’s emotional needs and mental problems through effective coping strategies in the clinical practices. Coping is an ongoing process that needs several cognitive efforts and energy to deal with the depressive stressors; it requires skills and strategies to give the terminal ill patient the ability to adjust and overcomes the environmental challenges or to reduces the stressors events in life. Though the level of depression and stress differ in terminally ill men and women the coping strategies doesn’t differ, in which the two most effective coping mechanism are social support and problem-solving strategies. In dealing with the depressive stressors the study on the patient past and present history is essential for effective problem solving, to decode and to address the stressors in the most effective and appropriate ways. It is the hypothalamic-pituitary-adrenocortical axis (HPA) and the sympathetic-adrenal-medullary (SAM) system of the human organs that are responsible for the mood disorders and negative emotional feelings that demands special assessment in the palliative end-of-life care [10,8].
The HPA and SAM not only have influence on the effects of stress in cancer metastasis, but also have several disease risks related physiological processes, effects the activity of immune cells, including natural killer (NK) cells, T cells, and macrophages as the outcomes of activating the stressful stimuli. In the midst of psychological stress, the involvement of the family and friends to give emotional support to the patient is considered to be the best coping mechanism to fight against the immunological and endocrinological consequences of the patient’s psychological functioning. The emotional and social support is visible in reducing the level of disease symptoms, depression and anxiety that reactivate and normalize the regular functioning of the patient peripheral nervous system and the central nervous system in the most effective ways. The immuno-modulatory therapy is also an important assessment in dealing with patient’s depressive stressors symptoms in the clinical practices [11, 9]. The psychotherapeutic intervention is more effective than the use of psychotropic medicines with regards to patient recovery from depression and wellbeing. Moreover, the merely use of counseling therapy alone without the psychotherapy has minimal impact to deal with the depress situation of the terminal patient. The person-centered therapy with holistic approach to terminal care can successfully encounter the psychological distress stems, emotional needs, reconstruct the cognitive stability and in building effective coping skills. The early intervention of the psychostimulant substances like dextroamphetamine or methylphenidate is also a well-recognized therapy against insomnia and hugely improves patient mood and wellbeing .
The intervention of the psychological approach to terminal care has been visible effective in three important dimensions for patient quality of life; in effectively reducing the psychological depressive stressors, increase the rate of patient survivor time period, and in decreasing the cancer metastasis rate. The collaborations of psychotherapy and psychopharmacological approach to terminal care is also found effective in decreasing the rate of tumor growth, boost-up the functions of the immune system, and in eliminating the depressive stressors that normalizes the patient condition into its normalcy and recovery . There are some existing measuring scales to measure the level of depression in terminally ill patient experience like The Hospital Anxiety and Depression Scale (HADS), The Zung Self-Rating Depression Scale (ZSDS), The Edinburgh Depression Scale (EDS), and The Nagi Disability Scale (NDS). The HADS is a fourteen-item scale depression rating tool use to indicate the antidepressant medical response, while ZSDS is a twenty-item self-reporting depression measurement scale use to indicate the present or absence or the level of depressive symptom in palliative end-of-life care patient. The EDS on the other hand, is a ten-item postnatal depression tool used to measure the symptoms like guilt, hopelessness, mood swing and other cognitive related process in terminally ill patient. The Nagi Disability Scale is mainly to identify the amount or the degree of psychological related sufferings among the cancer survivors [14,8].
The use of verbal screening instruments by forming some relevant questionnaires with regards to the low and high mood of patient undergoing depression can also enhance the treatment policy to address the depressive stressors. According to DSM-IV (Diagnostic and Statistical Manual of Mental Disorder) depression is mostly associated with patient’s loss of interest in daily activities, difficulty in making quality decision, psychomotor agitation and suicidal motive because of the disease effects, in which the psychological symptoms of depression is seen as the main characteristic of its outcomes. Thus, the early initiation of the psychological treatment within the adequate time period needs to be assessed. If the depressive symptom of hopelessness is not addressed in its early period, it can easily combine with the grief response that usually causes the loss of certain abilities in patient’s terminal experience. The primary concern of the clinician should be the adequate control over pain and symptom management and other disease risks in patient advance illness and to prevent the patient from certain depressive disorders through any possible means [15, 13]. Most importantly the assessment should be in a regular basis, which includes the appropriate time and place, intensity, quality, acknowledgement of the factors that exacerbate and the element that elevate the level of stress and depression in patient terminal experience. It is also important for the clinician working in palliative end-of-life care to identify the difference between the physiological tolerance, physical and psychological dependency, and pseudo-addiction in assessing the patient .
SUGGESTED COPING STRATEGIES
Among all the effective coping mechanism against stress and depression in terminally ill experiences, drawing positive attitude to self and the given environmental challenges by accepting the life situations which are beyond control and to adjust is the most effective coping mechanism for those with terminally ill experience. Striving towards self-esteem and learning the ability to relax over sensitive issues, rather than being aggressive towards what life brings. Adopting the habit of regular physical exercise, well manage in balance diet, avoiding things that creates sleeping disorder, abstain from the excessive use of alcohol and other related drugs are the core factors to eliminate stress and depression and to maximize quality of life by minimizing the depressive stressors. Diagnosis with cancer/terminal illness is a difficult experience filled with anxiety, negative emotional feelings, and mental disharmony, yet understanding the kind of tumor involve, its metastasis, treatment policy and the side effects would help in creating appropriate coping skills and the ability to deal with it in the most un-harmful way. Knowing the cultural and religion background is essential for every clinician, as in some culture death and dying is a taboo that has no place for public discussion. Preserving the patient autonomy by respecting the choice of the patient with regards to the disease risks information and the inclusion of patient in the decision-making management team is also important to produce quality of life in the end-of-life care . Honest conversations between the patient, clinicians, and the family on the disease and treatment outcomes cab serve as the platform where all the people involves in end-of-life care can come together for effective plan and policy to encounter with the environmental and psychological challenges in patient terminal experiences.
There is other better coping mechanism than the early interventions with proper treatment plan and policy in dealing with terminal ill diagnosis. Maintaining a healthy lifestyle with family and loved ones supports in every life situation is a worldwide phenomenon to fight against the cold-blooded killer cancer in the most effective way. The involvement of family, loved ones and the community in patient terminal experience is found as the best coping mechanism to meet the needs of the environmental demands like travelling, having quality times together, and creating good memories. Life review method is another coping mechanism that helps the patient’s in setting new lifegoals, which are having the maximum possibilities to achieve it before the inevitable death strikes. Helping the patient in managing their financial income for treatment expenses through any possible means can serve as the contributing factor to improve patient quality of life and wellbeing in the clinical practices. Forming a small cell group within the cancer affected community, which also includes the cancer survivors to discuss about their experiences, insights, feelings, the dos and don’ts in the cancer diagnosis is another strategy to fight against the cancer stigmas . The psychotherapeutic approach of relaxation towards the stressful events, the ability to keep one’s thoughts and feelings under control, keeping oneself busy by creating new hobbies, engage in outdoor activities like social services and attending religious services are among the most effective coping mechanism in terminal experience.
Spiritual coping mechanism is a modern humanistic approach to deal with stress and depression in the face of medical helplessness. The spiritual psychotherapy is a modern holistic approach to illness in health and medical sciences, which serve as an effective coping mechanism against several unwanted experiences like existential stress, anxiety, depression and emotional suffering that pre-occupied the terminally ill patient in terminal diagnosis. When cure becomes uncertain in terminal diagnosis spirituality becomes part of patient existence, having the potential to communion with self, others, nature, and the transcendent being. It is the coping mechanism that delivers the whole person treatment by addressing patient self-identity, inner peace, reconciliation, and hope with gratitude, which in turn deliver healing even when cure is not possible in terminal diagnosis. The involvement of psycho-social therapy is another effective coping mechanism that enables the dying individual to connect with the society where he/she belongs. It is the therapy that makes the patient experience the feeling of being valued by eliminating the existing social stigma of being an outcast [18,15]. However, the absence of anti-anxiety, anti-psychotic, and mood-stabilizing therapeutic approach to terminal care in the current health care system in India and other neighboring countries like Nepal, Bangladesh, Pakistan, Myanmar etc., the cancer/terminal patients undergo several unwanted feelings without any quality assessment. Due to the unavailability of the whole person treatment in the health care system of the country in general and in the medical curriculum in particular, the psychological stress and depression remain untouched in its clinical practices. Thus, India is considered as a country not to die by many.
Cancer is the disease that has effects individual physical health, emotional feeling, social life and having several psychological disorders as its outcomes. Being with cancer is the time when the individual develops unwanted habits like excessive use of alcohol and other related drugs to ease down their emotional suffering, pain symptoms, and mental disharmony. It is the times when they need people support the most to deal with their isolation, loneliness, hopelessness, anxiety and other depressive stressors. The psychological stress and depression not only destroy the patient’s peace of mind, but also possess the ability for cancer metastasis growth in the body parts and to disable the organs. The interplay between the environmental challenges, stressors and patient socio-economic, culture and religious background needs special consideration in cancer diagnosis to produce quality of life and wellbeing of the whole in the clinical practices. Developing positive mental health and healthy lifestyle is the core to cope with the psychological stress and depression in any terminal experiences. Moreover, even in the terminal stage when cure is not possible finding purpose and meaning in life can benefit self and others and is also an effective coping mechanism to overcome mental health problems.
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