Why our mental health matters, too

Millie Yager, a lively and outgoing 65-year-old Houstonian, loved working for the Astros and the Rockets. For 20 years, she worked in guest relations at every home game. Her job was fun and exciting, and being around the fans, players and her co-workers gave her so much energy. On a typical day, she walked 5 miles.

But by the end of the summer in 2015, a CT scan her doctor ordered after worsening fatigue, back and abdominal pain gave her the shocking news of her life. There was widespread metastatic cancer in her abdomen and large tumors on her ovaries. She had advanced-stage ovarian cancer, one of the most lethal cancers in women.

Ever the optimist, Millie knew she could get through it. She was ready to fight. I took her for surgery at MD Anderson in September to attempt to remove all her tumors. The surgery lasted 8 hours, well into the night. Afterward, my fellow and I, exhausted, went to speak to her husband, who had been anxiously waiting. "She is doing great." I told him. "I am so happy we were able to remove all of her tumors."

She recovered well, but this was the first battle of a long road to eradicate her cancer. She still needed 18 weeks of chemotherapy. As part of her regimen, she underwent chemotherapy both through an IV and a port-a-cath device that I had inserted under the skin of her abdomen during surgery. This is called intraperitoneal chemotherapy, as the drugs are poured into her abdomen and pelvis to kill off any residual microscopic cancer cells. Though it can be more toxic than IV, causing severe abdominal pain or nausea and vomiting, studies have shown that it leads to the best outcomes for patients with advanced ovarian cancer after surgery.

Millie battled through the side effects. But she found herself too weak to work, which had given her so much joy and meaning. Even doing her yard work, a hobby, was too exhausting. She could no longer go and work Rockets or Astros games. Now, she felt like she was a prisoner in a body that wouldn't allow her to do a lot the things she loved. She was feeling overwhelmed that this was her new normal, even if she were to live through her cancer.

After her last cycle of chemotherapy, she came into my clinic to review her post-treatment CT scans. Now thinner, hairless and gaunt with a flat affect, this woman was completely different from the energetic one she was before her cancer.

Naively, I tried to cheer her up by telling her the good news. "I looked at your scans, and you are now officially in remission!"

She did not respond. No smile. No eye contact. Looking dejected, she sat there silent in her chair, looking down at the exam room floor. Her husband said that in the past month she had lost interest in all the things she used to do. On a day that is for some a celebration, Millie looked as though the battle she had so valiantly endured had cost her soul.

Concerned about her reaction and behavior, I knew she was suffering from severe depression. I referred her to one of our psychiatrists. She was diagnosed with major depressive disorder and started the treatment that she needed.

I was thankful for that. But what many do not realize was how lucky we were to get her this care and to get it so quickly and easily.

This is because we are facing a mental health crisis in our nation. And it's even worse in Texas. According to the nonprofit group Mental Health America (MHA), Texas ranks 46th in mental health access. They estimate that 60 percent, or close to 2 million, adults with mental illnesses do not receive the treatment they need.

According to MHA, the two biggest groups in Texas that can't access care are disabled adults with a mental illness who can't afford the costs and individuals without insurance.

But even for those who are fortunate to have insurance or can afford the basic costs, there is still no guarantee they will find adequate care.

Texas is second only to Alabama in a lack of mental health workforce availability. According to MHA, the national average is one provider to 529 individuals. Texas has one for every 990. In a 2015 NPR story, Merritt Hawkins, a physician recruiting consulting firm, found that out of the 254 counties in Texas, 185 lack a psychiatrist. According to the firm's analysis, psychiatrists trailed only primary care doctors in demand.

Moreover, a significant number of mental health care providers do not take health insurance plans, because these providers might be inadequately reimbursed from both government and private plans. Patients can be then required to pay 100 percent of the cost, which can be out of reach for many.

Still, the overall problem goes beyond mental health. This is bad news for our physical health, too. The link between the two was recognized centuries ago. Around 2700 B.C., Chinese medicine conceived of health as complementary positive and negative forces. An imbalance of these forces contributed to illness. This concept of harmony and imbalance is known as "yin and yang."

Today, the leading causes of death in the U.S. are heart disease and cancer. In the past few decades, we are learning from a growing body of evidence about the association of psychological distress, such as depression and anxiety, with these two diseases. Therefore, a lack of adequate treatment for these psychological disorders will have substantial consequences on the prognosis of these deadly diseases.

For example, an analysis of 28 studies published in JAMA showed that patients with depression were 55 percent more likely to die as a result of a stroke. Last month, in the British Medical Journal, researchers analyzed data from more than 163,000 individuals from 16 studies and found that that severe psychological distress was associated with an increased risk of death from 16 different types of cancer. These included common cancers like breast, colon, lung, and prostate. Patients with severe psychological distress were more than twice as likely to have increased mortality with ovarian cancer.

We know that people who suffer from psychological distress typically have unhealthier lives. They smoke more; they drink more alcohol. They are more sedentary and eat unhealthier. Also, they might be less compliant with their doctors' recommendations and are even less likely to go see a doctor. Certainly, these behavioral factors can explain this link.

But the biological factors are also fascinating. Studies have shown that depression and chronic distress are associated with immune system dysregulation. Psychological distress can provoke an inflammatory response in your body. In oncology, we know some of the hallmarks of cancer include immune dysregulation and tumor-promoting inflammatory responses. The mechanisms linking psychological distress and physical diseases such as cancer remains elusive. Do the biological factors or behavioral factors explain this, or is it both? Broadly, this is a classic nature-versus-nurture dilemma.

As a nation, we have put such a high value on our physical health; we are willing to pay extraordinary amounts for drugs, surgeries and hospitalizations to help heal our bodies. Meanwhile, our mental health is largely relatively ignored. I would bet that more people are concerned about their last visit at the dentist. It is time that we remove the stigma attached to mental illness and elevate the value of mental health to deal with our overall health.

It has been one year since Millie finished her cancer treatments. Her salt-and-pepper hair has fully grown back, and now at her checkups I am greeted with her warm smile and a hug. I could see the charge in her personality is back, as she expresses the joys of her typical day, including her yard work.

Notably, she remains cancer free. Perhaps just as importantly, she remains depression free.

Dr. Behrouz Zand (@Behrouz_Zand) is Assistant Professor in the Department of Gynecologic Oncology at MD Anderson Cancer Center.

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