Chronic Wounds and Mental Health – An Overlooked Connection? published | 19 February When we think about our health, what often comes to mind are physical health issues like cancer, diabetes, and cardiovascular disease. These conditions do deserve significant attention, and certainly do pose a risk to our health. However, along with many of these conditions, there is another complication that does not garner as much attention, although it does significantly affect our health: our mental health. Chronic wounds are those wounds that do not heal in the expected time frame and do not follow the normal healing process. The result is an ongoing battle to overcome the wound and return to an active lifestyle. Coping with a chronic wound can feel like an uphill battle with no end in sight. This is also why chronic wounds can affect our mental health so dramatically – because they seem like injuries that cannot be overcome. What Is Mental Health? Mental health can simply be defined as the absence of mental illness. However, mental health deserves a much broader definition and more widespread recognition than it is given. It can be the difference between functioning at a satisfactory level and truly embracing and enjoying our lives, especially when it comes to chronic wound care The World Health Organization defines mental health as “subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one’s intellectual and emotional potential, among others.” Ultimately, our well-being includes the realization of our abilities, coping with normal stresses of life, productive work, and contribution to our community. Our mental health also affects how we think, how we perceive the world, the actions we take, and how we feel on a day-to-day basis. It can also contribute to how we handle life’s stresses, setbacks and failures, and our relationships. All in all, mental health encompasses just about everything we experience as humans, which is why it’s so important. According to the Centers for Disease Control, nearly one in five U.S. adults live with a mental illness (46.6 million in 2017), with an estimated 11.2 million adults aged 18 or older in the United States with what can be classified as a Serious Mental Illness. This means 4.5% of all U.S. adults cope with some form of mental illness. Many factors contribute to our ability to maintain our own mental health. These include any biological problems we may have, our life experiences, our family history, and any health conditions we are coping with – such as chronic wounds. How Do Chronic Wounds Affect Mental Health? According to the National Institute of Mental Health (NIMH), the presence of chronic conditions can increase the risk for mental illness. For example, conditions like Parkinson’s disease and stroke cause changes in the brain, which may trigger symptoms of depression. Depression is also common in people who have chronic illnesses such as cancer, coronary heart disease, diabetes, Alzheimer’s disease, HIV/AIDS, rheumatoid arthritis, lupus, and epilepsy, among others. Chronic illness can also cause feelings of illness-related anxiety and stress related to coping with wounds. Moreover, when depression and anxiety are present, the symptoms, as well as those of the chronic health condition, tend to be more severe. The NIMH also says people with depression are at higher risk for other medical conditions. As an example, people with depression have an increased risk of cardiovascular disease, diabetes, stroke, Alzheimer’s disease, and osteoporosis. One explanation for this is that mental illness may interfere with the ability to cope with chronic health conditions. For example, with mental illness present, a person may find it more difficult to seek care, take prescribed medication, eat well, and exercise. Lastly, preliminary research suggests that symptoms of depression and anxiety can cause signs of increased inflammation, changes in the control of blood circulation and heart rate, increased stress hormones, and metabolic changes that increase the risk of diabetes – all of which impact our health and our ability to cope with chronic health conditions. How Can Mental Health Be Improved While Coping with Chronic Wounds? The process of wound healing comes in four stages and it’s imperative to maintain mental health throughout each of them. While the most common treatment strategies for mental illness include cognitive behavioural therapy (CBT), medication, such as selective serotonin reuptake inhibitors, (SSRIs), and, in the most severe cases, electroconvulsive therapy (ECT), there are many lifestyle changes that we can incorporate every day to improve our mental health. Psychology Today suggests the following nine, all of which apply especially to chronic wound care patients: Be positive. While it is easy to overlook the automatic thoughts that run through our heads, when combined, they can add up to a negative outlook. When we see life through a negative lens, we tend to focus more on the things that confirm that belief. On the other hand, when we incorporate positive thoughts, these often lead to positive interpretations. For example, rather than saying, “I can’t do anything right,” try saying, “It didn’t work out this time, but I will try again.” Be grateful and write it down. It’s now clear that feelings of gratitude do significantly affect our mental health. When we can find things in our lives to be grateful for, not only do we feel differently, we also act differently – in ways that often lead to additional mental health benefits. One quick way to start is to keep a gratitude journal, or better yet, try practicing three acts of gratitude every day. Focus on what we can control, and be in the moment. Both ruminating about the past and forecasting the future can cause feelings of regret, depression, and anxiety. We can’t do anything about the past or the future. However, what we can do is stop and choose to focus on what we can control – our actions in the present moment. One easy way to do this is to simply pay attention to your routine activities and the thoughts that accompany them. Get active. Exercise is one of the most palpable ways to gain a sense of control. When you exercise, despite what else is happening in your life, you remind yourself that you can do something positive for your mind and body. Further, exercise increases stress relieving and mood lifting hormones, which have both an immediate and ongoing effect. Exercise can be incorporated in 30-minute blocks, or you can simply look for small ways to increase your activity level, like taking the stairs, going for a walk, or playing with your dog. Eat right. What we eat provides our brain with the ingredients to function well and improve our mood. Carbohydrates increase serotonin, which makes you happy, while protein-rich foods increase norepinephrine, dopamine, and tyrosine, which help keep you alert. Fruits and vegetables provide nutrients that feed every cell in the body, including mood-regulating brain chemicals. Lastly, foods with Omega-3 polyunsaturated fatty acids (found in fish, nuts, and flaxseed) can improve both our cognitive function and our mood. Open up. When we bottle emotions up, we don’t give ourselves an opportunity to cope and find creative solutions. We also dampen our ability to recognize our own habits, which may be contributing to how we feel. On the other hand, when we open up to someone else, we can pinpoint the positive aspects in other people (such as feeling valued or experiencing a sense of trust) and overcome our own biases. Do something for someone else. Like acts of gratitude, being helpful to others has a beneficial effect on how we feel about ourselves. Moreover, being helpful helps us feel valued, which contributes to positive self-esteem and helps us find a sense of meaning in our lives. Chill out. Sometimes in moments of high stress what we really need to do is step away. Often by simply slowing down, we can gain a greater perspective on what is going on, and in the process, find a positive solution. You can start with focusing on something that brings you positive feelings, such as a person that you love, an experience you enjoy, or something you are grateful for. You can also talk a walk, spend a moment in nature, or close your eyes and visualize yourself feeling calm and at peace. Get a good night’s rest. Sleep deprivation has a significantly negative effect on our mood, and sadly many of us don’t get enough sleep. Sleep can be improved with a few daily habits such as going to bed at a regular time each night, avoiding caffeinated beverages for a few hours before sleep, shutting off screens before bed, or incorporating relaxing activities before bed. There are many powerful components of mental health, like enjoying our lives, feeling as if we are striving toward something important, utilizing our skills, and seeking to reach our full potential, to name a few. And while chronic health conditions are often an overlooked deterrent to mental health, incorporating daily habits -i.e. replacing automatic negative thoughts with positive ones, performing acts of gratitude, staying in the moment, exercising, eating well, opening up, being helpful, taking time out, getting enough sleep, etc. – we can combat mental illness even amidst difficult chronic health conditions. Written By: Claire Nana Claire Nana, LMFT, is a Licensed Marriage and Family Therapist who specializes in post-traumatic growth, optimal performance, and wellness. She’s written over thirty continuing education courses on a variety of topics from Nutrition and Fitness, Mental Health, Wound Care, Post-Traumatic Growth, Motivation, Stigma.