Tip 1: Exercise

Regular physical exercise helps maintain mental health and boost our mood. In fact, regular moderate physical exercise has been studied and included in our psychiatry guidelines as an approach to help treat depression.

Tip 2: Sleep

Good sleep habits can help improve our mood and prevent mental illness. One third of our lives is spent sleeping, so learning good sleep habits is definitely worthwhile.

Tip 3: Balanced Thinking

We can change our mood by changing how we think. If we notice we are having all or nothing thinking (for example,  “nothing goes my way”, or, “no one likes me”), practice making those thoughts more balanced by seeing the other side of things (“some things don’t work out for me but other things do”, or, “some people like me while others don’t like me”).

This is a key component of cognitive behavioural therapy and can actually help us start to change our moods to become less depressed or anxious and more positive and balanced.

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For those who are unable to naturally maintain this rhythm—or those who have difficulties breathing, resting, or staying asleep—there are a growing number of new technologies that aim to make the process of resting well more accessible.

Sunnybrook is home to a state-of-the-art research, education, and sleep laboratory that combines brain science-based clinical abilities, teaching, and research, as part of the Clinical Neurophysiology program.

At the most recent edition of our Speaker Series community education session, “A Good Night’s Sleep,” Sunnybrook experts Dr. Andrew Lim (highlighting circadian rhythms), Dr. Mark Boulos (focusing on restless legs syndrome), and Dr. Anu Tandon (sharing about sleep apnea) presented to community members about a range of sleep-related health issues and also had the opportunity to provide real-time feedback and information to participants in the live webinar moderated by Dr. Brian Murray.

A common topic and point of interest: the use and benefits of positive airway pressure therapy.

CPAP, APAP & BIPAP

There are three main types of positive airway pressure therapy:

• CPAP: Continuous Positive Airway Pressure delivers consistent pressure maintained throughout the respiratory cycle to improve oxygenation.
• APAP: Automative Positive Airway Pressure automatically adjusts to meet each person’s specific needs, changing throughout the night to constantly measure resistance.
• BIPAP: Bilevel of variable Positive Airway Pressure is low-range pressure, that delivers higher air pressure when you breathe in.

In addition to these familiar therapies, there are also dental and nasal options, surgical alternatives (nasal or jaw), and nerve stimulation.

Technological sleep innovations

Sleep technologies that collect information while resting in a natural environment and recording information over an extended period of time can also include various pedometers and related trackers. Fitbit® (for example), or similar devices can measure metrics like heart rate, temperature, oxygen levels, and assesses quality of sleep and physical activity.

To assist in discovering sleep abnormalities, Sunnybrook’s Dr. Lim highlighted a few innovative wearable technologies, including:

• MUSE is a brain sensing headband that uses real-time biofeedback to help refocus during the day and recover overnight; it determines when psychology and physical problems arise within the body, with guidance for combatting stress and overcoming fatigue.
• The ANNE^TM ONE system, for the diagnosis of obstructive sleep apneas in adults, is worn over multiple nights in a row, monitoring and predicting when breathing stops during sleep.
• WRIST ACTIGRAPHY devices are wrist-worn monitors that record movement and sleeping or talking patterns over an extended period.

How is your sleep hygiene?

“Healthy sleep is paramount to a healthy lifestyle.” Dr. Mark Boulos, Sunnybrook Neurologist

Here are a few things to consider when monitoring and improving your sleep hygiene:

1. Establishing a fixed wake up time
2. Prioritizing your sleep over other activities
3. Making gradual adjustments to your routines
4. Limiting the amount of naps taken during the day
5. Winding down before going to sleep
6. Dimming lights for a quiet and relaxing sleep environment
7. Unplugging from electronics before bedtime
8. Getting as much daylight exposure as you can
9. Optimizing your bedroom (limiting use for sleep and sex only)
10. Refraining from eating or drinking before going to sleep

Sunnybrook’s Sleep Disorder Clinic

For those who would like to visit Sunnybrook’s Sleep Disorder Clinic, ask your family doctor for a referral if you are experiencing symptoms of concern, including:

• Sleepiness or features of narcolepsy
• Loud snoring or stopping of breathing in sleep
• Restless legs syndrome
• Abnormal sleep behaviours

Have your family doctor fax a brief request to “assess sleep” to 416-480-6092, to arrange clinical assessments and necessary sleep studies: click here for our Outpatient Sleep Assessment Request Form.

Coming soon from the Hurvitz Brain Science program

Sunnybrook’s Hurvitz Brain Science program is growing, with a new Circadian Rhythm Lab on the horizon. To learn more about sleep research taking place within the Hurvitz program, or if you are interested in supporting fundraising efforts, please visit link here for more information.

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All of the things that the brain is responsible for – physical and mental – are part of brain health. While often spoken about separately, mental health is a central part of brain health – they are not separate or distinct.

Mental health is brain health.

Understanding this can help to reduce the stigma that continues to be associated with mental illness, which, like any physical disorder or disease, is a health problem and requires appropriate treatment.

One of most important things that people don’t often realize is that the three major brain conditions of our lifetime; stroke, dementia, and depression, are all inter-related. They are all happening in the same organ, and if person has been diagnosed with one of those three conditions, their risk of the other two conditions increases.

That is to say: if an individual has a stroke, it increases their risk of having post-stroke depression and developing dementia; if someone has dementia, there is an increased risk of developing depression and having a stroke; and having clinical depression, increases the risk of going on to have stroke and/or dementia.

What affects brain health

Any disruptions to the brain can affect the way it works. The brain is an incredibly vascular organ – there are a rich supply of arteries and veins that help with the delivery of nutrients to the brain, as well as the removal of toxins and by-products of metabolism, to keep it healthy.

When that blood flow is interrupted, it affects brain function and that results in changes in the way information travels along the brain’s pathways. This can impact how we move, how we sense things like hearing or touch, the way we think about the world and people around us, how we perceive a situation, and how we behave.

It is important that brain conditions are understood and treated from multiple perspectives at the same time. Traditionally, the various medical specialties that deal with brain conditions would treat disorders individually; for example, if a person has a stroke and needs a blood clot removed, they will be seen by a neurosurgeon or neurologist. If a person has depression, they will be treated by a psychiatrist. If a person has dementia, they might see a neurologist or a psychiatrist.

But the new way of understanding and treating brain conditions involves a broader and more collaborative approach.

A multi-disciplinary approach to brain health

Sunnybrook’s Garry Hurvitz Brain Sciences Centre will connect brain health experts from across medical disciplines in the same building.

Bringing brain specialists together to collaborate with one another will help enhance a patient’s treatment, education, and will pave the way for possible new discoveries of the causes and potential treatments of brain conditions.

For stroke, depression, dementia, and other brain conditions, including sleep disturbances, anxiety, Amyotrophic Lateral Sclerosis (ALS), tremor, and others – having a broad range of the brain specialities and disciplines, including neurology, neurosurgery, psychiatry, psychology, and more, working together for improved patient care, is really the way of the future.

For more information about brain health:

• Learn more about Sunnybrook’s Garry Hurvitz Brain Sciences Centre
• Q & A with Dr. Levitt about Sunnybrook’s Garry Hurvitz Brain Sciences Centre
• Learn more about the Hurvitz Brain Sciences Program at Sunnybrook

If you need help in an emergency, please call 911 or visit your local emergency department.

If you’re feeling like you’re in crisis or need somebody to talk to, please know that help is also available through community resources:

• Find a local crisis resource at sunnybrook.ca/gethelp
• Crisis Services Canada
  • Phone: 24-hour, toll-free 1-833-456-4566
  • Text: 45645 (4:00 p.m. – midnight Eastern Time)
• Kids Help Phone
  • Phone: 24-hour, toll-free, 1-800-668-6868
  • Text: 686868 (24 hours, 7 days a week)

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Karin, being a here-and-now, one-step-at-a-time kind of person, coped more calmly than me. Desperate to regain a feeling of control, I coped with my shock and distress by springing into hyper-focused, goal-directed action. I focused my efforts on trying to connect us to expert services. My take-charge manner was very necessary at that stage, but my high need for control could have become a problem beyond that point.

During our first appointment with the oncologist, he astutely recognized my personality type and assertively told me to step back and let him take over. He cautioned me to not try to research and interpret medical information or make treatment decisions: he was in charge. At that moment, I felt like I had been standing outside my burning house with a garden hose after calling 911. Several fire trucks with lights flashing and sirens blaring had pulled up. I felt I had been politely but urgently pushed aside, told by the fire chief “You can step back now sir!” I was anxious relinquishing control, but at the same time immensely relieved.

From that time on, we just showed up for treatment and hoped for the best – we simply put our energies into engaging fully in daily life. We focused on the priority of taking care of our children, our relationship, spending time with extended family and friends, and doing meaningful work.

Many people urged us to be more ‘proactive’ about ensuring Karin’s health. We received a lot of unsolicited advice from many different quarters regarding treatments, alternative therapies, and healthy lifestyle measures which were said to be assured to beat the cancer and prevent recurrence. Most of the advice, while well-intended, involved measures lacking any reliable evidence.

Karin and I were painfully aware of the prognostic uncertainties of her cancer. We had a strong sense that there was nothing we could do to alter the not very reassuring statistics of the best available medical treatments. This realization was deeply unsettling, and the urge to deny it and believe otherwise was very strong.

When you’re diagnosed with cancer, it’s natural to wonder “What did I do to cause this?” and “What can I personally do to re-take control and improve the outcome?” But this need to identify causes and solutions in order to feel in control is a double-edged sword, fraught with potential for guilt and self-blame. The reality is that most of the factors causing cancer are either random or so biologically complex that for practical purposes, we can regard them as random, and beyond our control.

Most people don’t like the idea that randomness rules our lives. Studiesⁱ show that when we feel insecure and lacking control, we are even more likely than usual to perceive illusory patterns of causation. Patients commonly over-estimate the role of their own actions or lifestyle in causing their cancer and in determining the future course of their illness. Too often, people become excessively obsessed with things like diet, when what they really need to do is focus on the things in their life that give them meaning, and matter most to them.

Furthermore, many people cope with adversity by believing that life events happen for a cosmically intended reason. This belief too is a double-edged sword: while it can comfort some people, others, whose adversity seems to have no redeeming features, feel anguished or alienated by the inevitable question ‘Why me?’ In my psychiatric practice I have counseled many such people, whose experiences with illness or catastrophic life events have left them struggling to come to terms with the randomness of life.

Twelve years later, Karin remains in remission (though she did have a recurrence five years ago, which fortunately turned out to be minor, after several frightening weeks of uncertainty). One is never really out of the woods with cancer.

Despite all the anxiety and uncertainty, or maybe because of it, Karin’s and my experience of her cancer heightened our sense that our lives are suffused with meaning. I don’t want to romanticize the experience with the selective memory of hindsight, but some of our most moving and meaningful interactions with people occurred in our time of crisis. We were the grateful beneficiaries of very much kindness and caring. We had a great sense of clarity of priority and purpose. Relationships mattered most to us. For quite a while we didn’t ‘sweat the small stuff.’ We have tried to keep these lessons in mind, even though human nature relapses much more surely than does cancer, and we find ourselves ‘sweating the small stuff’ all too often now.

To be clear, all this meaning was made by us and by our support system and by other caring people; everyone was doing their utmost to make the best of a really bad situation. I don’t believe that the meaning of such a life circumstance is predetermined – none of the good that came from it was ‘meant to be’. (How can anyone in good conscience judge their own circumstances as having ‘happened for a reason’ when thinking about their own positive outcome, knowing that others have unmitigated tragic outcomes?) Nor am I endorsing the ‘cult of positivity’ surrounding cancer – I would never suggest that ‘cancer was a blessing’. It could have turned out very badly. We fully recognize that our positive outcome was heavily determined by dumb luck.

Coming to terms with randomness is frightening, but it does liberate us from the tendency to blame ourselves for illnesses we didn’t cause. It also ought to stop us from judging others for their misfortune. And an understanding of randomness should make us think twice about pressuring people with unhelpful advice of unproven therapies that are based on mistaken attributions of causality.

People with different personalities differ in how intensely they need and expect to be in control of their livesⁱⁱ, and in their level of anxiety when experiencing a lack of control. As a naturally high-control person myself, relinquishing it when circumstances required doing so did not come easily to me. My work now often involves trying to help patients with high-control personalities like mine who are experiencing random adversity to recognize the limits of their control. People like us need help letting go, tolerating uncertainty, and focusing on living life to the full, as meaningfully as possible. Here and now. Each day is precious and uncertain. In this way, cancer is just like life in general, only more so.

i. Whitson, J. A., and A. D. Galinsky. “Lacking Control Increases Illusory Pattern Perception.” Science 322, no. 5898 (Oct 03 2008): 115-7. 

ii. The personality trait we are talking about is also referred to as conscientiousness, which is considered one of the ‘Big Five’ personality traits:  https://en.wikipedia.org/wiki/Big_Five_personality_traits

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For nearly two decades, Dr. Laflamme, 53, has helped care for patients as a cardiac anaesthesiologist at Sunnybrook Health Sciences Centre. During most of that time, he was a patient too: for years, he lived with chronic renal disease.

By 2012, however, his disease had progressed to the point that he needed a kidney transplant. “I was told to start looking for a living donor. Otherwise, I would have to go on dialysis,” says Dr. Laflamme.

Fortunately, he was able to avoid dialysis by finding a living donor in time. His sister, France, donated her kidney to him in 2014.

“After receiving my kidney, I was determined to take care of it and treat it with respect,” says Dr. Laflamme. “My sister made a huge sacrifice by becoming a living donor, so if nothing else, I wanted to honour her decision by living a healthy life.”

He began cycling as part of his commitment to a healthy lifestyle, and before long, he was riding four or five times a week. Last year, a friend mentioned that he might be able to participate in the 2017 World Transplant Games (WTG) in Malaga, Spain.

“I had never heard of the event, but once I looked into it, getting to the Games became a huge motivator for me,” says Dr. Laflamme.

By his own admission, Dr. Laflamme was not an athlete before his transplant, and he had never competed in cycling before. Upon arriving at the WTG in June, though, he realized the event was about much more than winning medals.

“It was so inspiring to see all of these incredibly fit people, people you would never know had a transplant by looking at them, leading such healthy and active lives. The camaraderie among the participants was really amazing,” he says.

As an athlete living with a transplant, Dr. Laflamme says one of the largest obstacles to participating in sports is dealing with the side effects of the many medications transplant recipients must take. Some medications can affect balance, while others can cause muscle pain.

The biggest barrier, however, is often psychological. “For many of these organ recipients, they’ve lived with chronic disease for so long that they don’t know what it’s like to be healthy,” he says.

That inspired Dr. Laflamme to become an official Fit for Life ambassador for the WTG Federation, providing education and encouragement to other transplant recipients about getting involved in competitive sports.

“I’m helping to create a community of transplant recipients and teams where we can talk about goal setting, motivation and coaching. I didn’t have access to those kinds of resources after my transplant, and I think it would have helped so much during my recovery,” says Dr. Laflamme.

During this year’s WTG, Dr. Laflamme competed in three events: the 5km time trial, the 20km team ride and the 32km individual ride. He plans to add another event, running, to his schedule for the next WTG event in 2019, and has already started training with a coach.

“I haven’t felt this good in twenty years. Post-transplant, I’m healthier now than I’ve ever been.”

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What causes fatigue?

There are many causes of cancer-related fatigue and often a person will have more than one reason for being fatigued at any given time. There are treatments and things you can do to help with fatigue.  Talk to your health care team  about some of the causes of fatigue.

• It is important to remember that your body is fighting against your cancer.  This is very hard work and can result in the feeling of fatigue.
• Cancer treatments can cause fatigue. It is very common for a person who is getting chemotherapy or having radiation treatments to feel fatigued.
• Another common and treatable cause of cancer-related fatigue is anemia.  When a person is anemic, it means they have fewer red blood cells in their bloodstream than what they would normally have.  Anemia can be caused by cancer itself or can be a side effect of treatments. Sometimes anemia can be treated with medications that increase the body’s production of red blood cells. If you have anemia, your health care team might suggest that you receive a blood transfusion.
• When a person has been told they have cancer or is having treatment for their cancer, it is very common for this to be an emotional or distressing experience.  This can make a person feel fatigued.
• It is very common for a person with cancer to have trouble with sleeping.  Waking up often during the night and not getting enough sleep can make fatigue worse.
• Other symptoms like pain, trouble breathing and nausea (feeling sick to your stomach) can result in fatigue.

What’s important for me to know about fatigue?

Just like pain or nausea (feeling sick to your stomach), fatigue is a real symptom and it can have a big impact on your life.  You might think you are expected to feel fatigue when you have cancer.  You might also think it is not something you need to tell your health care team about. . There are things that can help you feel less tired and it is important for you to talk to your health care team about your fatigue as different suggestions can be made depending on the underlying cause.

Sometimes a person is worried their fatigue might mean their cancer treatment is not working. If you are worried about this, please discuss this with your health care team.

It is important for you to know what you can do about cancer-related fatigue:

• Exercise regularly (this is the most effective thing you can do to improve your fatigue)
• Keep a journal or diary of how you feel each day. This can help plan daily activities
• Let others help with tasks that need to get done (for example laundry or cleaning)
• Save your energy for the things you enjoy doing
• Don’t be afraid to ask for help. Friends and family might be willing to help, but may not know what to do.
• Try to balance activities with rest.
• Take one short nap not longer than one hour during the day.  If you find you need to sleep more than this please speak to your health care team as this may mean that there are issues other than fatigue that need to be looked at and explored further.

When should I speak to someone about the fatigue I’m feeling? When should I be concerned?

One way to think about whether you should speak to someone about the fatigue you are feeling is to think about how it is affecting your life.  If you are worried or distressed about the fatigue you are experiencing, speak to your health care team.  Also, you can ask yourself these three questions:

1. Am I more tired in general than before I had cancer?
2. Am I too tired to do things like go grocery shopping or go out for dinner with friends?
3. Am I too tired to get out of bed in the morning or get dressed?

If your answer is “Yes” to the first two questions, be sure to discuss fatigue with your health care team during your next visit.  If you also answer, “Yes” to the third question, you or someone you know should contact your health care team right away.  It is concerning if your fatigue is bad enough that it impacts your ability to do things like get out of bed or get dressed.

Fatigue is very common for a person living with cancer.  Many of the underlying causes of fatigue have treatments and ones that you can do yourself without the use of medication however just to be sure that you are following the right path and that there is no other reason for your fatigue it is important to to tell those caring for you at the place you are getting treatment so they can determine what the cause is and to jointly develop a plan to help you.

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Managing cancer fatigue through diet: what to eat, when to eat, and other nutrition tips

Eating reference »

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Managing cancer fatigue: Family and support. You need your family and friends to help you manage expectations throughout your illness. Tips on how to do so.

Support & family reference »

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Managing cancer fatigue through sleep: tips, and ways to tackle sleep-related issues.

Sleep reference »

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Improving your thoughts, behaviours and attitudes surrounding cancer fatigue can help combat it. Here are some tips on reducing stress for clearer thinking

Stress reference »

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