The belief that ‘staying positive’ impacts peoples’ cancer outcomes is not an uncommon one. Surveys show that the majority of patients and even oncologists subscribe to this belief! But scientific research suggests a very different picture. Studies have not found that depression causes cancer or worsens cancer outcomes, and similarly, research has failed to show that treating depression improves cancer outcomes. So why the confusion?

First off, let’s clarify. I often hear people confuse ‘feeling depressed’ with ‘being in a depression’. These are not the same. Feeling depressed (aka, feeling sad, feeling down, feeling low, etc.), is a normal part of the human experience. We have all felt sad at times, and feeling sad or depressed is one of the many emotions we can experience as part of the broad range of normal human emotions. Being in a depression (the medical terminology is Major Depressive Disorder) is an actual medical diagnosis which is much less common and which affects people beyond how they feel. It affects their thinking, their behaviour, and impairs their overall functioning. Many of the folks I encounter confuse these terms, and it’s not uncommon for someone to tell me that they believe they are suffering from depression when, in fact, what they are experiencing is not depression (the disorder) but sadness (the emotion). There is, indeed, a correlation between mood disorders and healthcare outcomes, including cancer, (More on that below. Keep reading.) but what is less likely is a correlation between feeling sad and cancer outcomes.

Secondly, we have to remember that correlation (i.e., association) is not the same as causation.

To better understand this concept of correlation versus causation, consider this: in the summer months, the amount of ice cream sales increases. So does the number of car accidents. Ice cream and car accidents are, therefore, correlated with one another. But we all know that ice cream does not cause car accidents. So while it’s true that ice cream is correlated with car accidents, it would be misguided to advise people to avoid ice cream as a way of reducing the number of car accidents!

Back to cancer: depression (the disorder) is correlated with worse healthcare outcomes, as has been shown in many studies in cancer and other illnesses. But this is probably best understood by remembering the ice cream example. What we know about many diseases, including cancer, is that we often find higher rates of depression among people who are sicker or suffering more, physically. It might be tempting to therefore infer that depression leads to people being sicker, but that would be inaccurate. The best we can say is that there are higher rates of depression in groups of people who are sicker.

Putting it all together, there is strong evidence for a correlation between major depressive disorder and a number of health outcomes, both in cancer and in other illnesses. But this does not mean that major depressive disorder causes cancer. In fact, there is no evidence to support this claim, and studies have found that treating depression does not lead to improvements in cancer. What’s more is that most people will never be diagnosed with major depressive disorder, and feeling down, depressed, worried, anxious, scared, upset, among many others, is part of the normal human experience. These emotions, in their own right, have not been shown to impact cancer outcomes.

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But there’s lots of talk about “staying positive” when it comes to cancer diagnosis and treatment. Here, Dr. Elie Isenberg-Grzeda, psycho-oncologist at Sunnybrook’s Odette Cancer Centre, tackles a few of the common questions he receives about positive thinking and cancer.

When it comes to my cancer diagnosis, treatment and mood, I’ve heard “fake it ’til you make it” and “put on a brave face” from family and friends. Do those things help?

I often tell my patients that these things can help for some people, but I make sure to be clear about what they can help with. There is no scientific evidence that these things help with cancer outcomes, but that doesn’t mean they can’t still help with something. For example, when someone is feeling down or depressed — whether due to cancer or anything else — they may withdraw and isolate themselves from social activities. This can lead people to become further depressed because by isolating themselves, they miss out on opportunities for social encounters that might otherwise help cheer them up. There is a therapy called behavioural activation, whereby people work with a therapist to try re-engage them in activities that might allow for more positive reinforcement. This might include something as simple as showering or getting dressed in the morning, or it could include something as demanding as planning an outing. Almost invariably, these are positively reinforcing and rewarding experiences, but at least initially, I can understand how some of these techniques might lead people to feel like they are “faking it until they make it”.

Are there any other benefits to trying to stay positive?

This really depends on each individual. For some people, cancer can cause them to feel completely powerless, and staying positive might be an important way for them to feel like they have some power or some control over their illness. That same person might feel like they are betraying themselves, their family, or their community by not staying positive. So I can see how staying positive might be extremely beneficial for that individual, given their personal belief system, their background, and their need to feel like they are truly ‘doing something’ to help their illness.

I’m feeling down. Now I feel guilty that I feel down because what if that affects my cancer? What do you say to that?

The whole idea of staying positive is really a double-edged sword because it can clearly help some people (as mentioned above), but at the same it, it’s hard to imagine that anyone can stay positive all the time, particularly when negative feelings (e.g. sad, angry, worried) are so natural following a diagnosis of cancer. It’s not uncommon for patients to come see me, not because they are feeling badly about their cancer— as we would expect — but because they are feeling badly about not staying positive all the time. We call this the ‘tyranny of positive thinking’. (Definition of tyranny: cruel and oppressive rule). In those cases, the goal will be to help relieve someone of the burden of being all positive all the time. The good news is that the scientific evidence does not support the notion that staying positive is important for cancer outcomes.

In other instances, people worry that if they don’t stay positive, then their family might think they are not coping well. The truth is that it is completely normal to feel sad about something that is sad. By not expressing sadness when sadness is due (e.g., by putting on a brave face all the time), we may be modelling to those around us, perhaps inadvertently, that it’s not ok to talk about things that are sad. For parents of young children, for example, staying positive is almost always a parent’s way of wanting to protect their children, but the unintended message to those children is that it’s not ok to talk about sad things, such as a parent’s cancer. For spouses or other family or friends, staying positive might create distance in relationships if the partner perceives a similar message in their partner’s positivity: that it’s not ok to talk about things that are sad. These are just some examples of many unintended consequences of staying positive.

So when someone feels bad for feeling sad, I try to validate what they are feeling and normalize it for them with the hopes of unburdening them from the tyranny of positive thinking. Usually, people are glad to hear to that the scientific evidence does not show any causal relationships between thinking positively and cancer outcomes.

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