Mental Health and C. difficile
Quick Facts
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Chronic stress from both physiological and psychological sources compromises the immune system
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The bidirectional relationship between the brain and the gut (the brain-gut axis) is a critical aspect of immune function and the gut microbiome
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Lack of social support, certain antidepressants, and depression are all associated with an increased risk of developing a C. difficile infection
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CDI has far-reaching effects on many aspects of patient’s related quality of life, not just health-related
The Science of Stress
Stress occurs when circumstances or events in your life, called stressors, surpass your abilities to cope, leading to physiological and psychological stress responses. Your body views stress as an acute threat that disrupts us from our normal balance, regardless if the source of that stress is physical or mental (1). All of our body systems fluctuate in response to stress; hormones such as cortisol are released, and our immune system changes. Laboratory studies have shown that short-term stress activates our immune system, mobilizing immune cells into the bloodstream to prepare the body for injury or infection that may come from “fight or flight” (2). A hormone that you may have heard of called the “stress hormone”, cortisol, limits inflammation which prevents tissue and nerve damage while giving us energy to deal with the stressor (3, 4).
However, chronic stress–lasting from a few days to a few months or year–has a different effect on the body. Although cortisol can boost immune function short-term, over time your body adjusts and rebalances to a high level of cortisol, which can actually lead to an increase in inflammation and a resistance to the effects of cortisol (3). Chronic stress decreases your white blood cells, which are critical in helping fight off any intruding microbes that could induce infection (2). Immune cells also change in how they respond to signals such as neurotransmitters and hormones from your body, which reduces their ability to move throughout the body and respond to infection (5).
These effects compromise your immune system, leaving you more vulnerable to infectious pathogens such as bacteria or viruses. Your immune system under stress is tired and overworked and cannot properly protect you.
What does stress have to do with C. difficile?
Stress, both acute and chronic, can have short and long-term implications for gastrointestinal functions (1). Exposing the body to stressors, whether a physical threat, such as an infection or psychological stress, causes the brain-gut interactions to be disrupted (1). The brain and the gastrointestinal tract communicate via the brain-gut axis; this is how the two organ systems talk to each other and regulate one’s health, including immune function and gut microbiota activity among others (1). Stress can compromise the intestinal barrier that protects the body from potentially harmful chemicals and microorganisms (6, 7). If bacteria such as C. difficile cross the more porous gut lining, they can activate an aspect of immune defence called mucosal immunity, which disrupts the balance of the microbiome (7). As we discussed in the Gut Microbiome module, a dysregulated microbiota can affect the body’s ability to fight off infections – check out that page here for more information.
What can I do to manage my stress levels?
Mindfulness: Also known as meditation, mindfulness has been associated with improved mental health and stress reduction. Even taking 10-15 minutes three or four times a week to meditate, be aware of your breath and body, can be beneficial in a number of ways. Research has demonstrated that meditation affects four factors: present-centred attention, acceptance of experience, clarity about one’s internal experience, and the ability to manage negative emotions (8). In terms of stress, mindfulness has been shown to reduce cortisol levels and lower inflammation (9, 10). Studies have also demonstrated the effectiveness of mindfulness in improving psychological outcomes in stress, chronic pain, anxiety, depression, and overall quality of life (11, 12).
Other self-guided strategies for stress reduction (with scientific evidence behind them!) include progressive muscle relaxation, guided imagery, and diaphragmatic breathing (13, 14).
Isolation, Mental Health, and CDI
Rates of depression are currently on the rise globally, and remain among the leading causes of disability worldwide (15). Among countless other concerns associated with living with depression, recent studies have shown that there is an increased risk of acquiring a C. difficile infection (CDI) – specifically, 36% higher than those without major depressive disorder (16). This increased susceptibility to CDI extends to individuals with major depression and depressive disorders, who have reported psychiatric, emotional, or nervous issues (16). Research has shown that in depression and/or the consumption of certain antidepressants (specifically the combination of mirtazapine and trazodone) can promote the development of CDI (16). Effects of depression have been shown to induce alterations in the gut microbiome and increase intestinal permeability, which may be a possible mechanism for this increased risk (17).
There are two general forms of isolation that one can experience: social disconnectedness, which includes a lack of social relationship and participation in social activities, and perceived isolation, which is defined by loneliness and perceived lack of social support. Social isolation has been linked to worse health across age groups (18); isolation protocols are a cornerstone of infection prevention, and C. difficile patients are almost immediately placed in isolation upon their diagnosis (19). In an infection that can last weeks, even when released from the hospital, patients have reported the collapse of their social life due to diarrhea and other symptoms that prevented participation in their daily activities (20).
In terms of C. difficile infection incidence, loneliness itself can be considered a risk factor: widows and individuals who live alone are more likely to acquire CDI (16). The humiliation and embarrassment that patients feel when struggling with a CDI (20) may only augment the feeling of loneliness. The isolation due to CDI may only be compounded by the pervasive stigma of discussing bodily functions, particularly anything related to the gastrointestinal tract. Furthermore, a lack of social support has been reported as a risk factor for depression (21); social isolation and feelings of loneliness are also factors that weaken the immune system (22, 23). Although at the time of preparation, there has yet to be a study investigating a direct link to CDI, these findings support a growing body of evidence that social and mental factors influence the function and composition of the gastrointestinal system and immunity (16).
How is quality of life impacted by this infection?
A reduction in health-related quality of life is one of the many burdens borne by patients diagnosed with C. difficile infection. The most affected dimensions reported were usual activities, mobility, and self-care, in addition to significant impairment in anxiety, depression, and pain (24). CDI patients have also commonly reported high anxiety rates, specifically identifying concerns specific to CDI, including worry about future complications, physical concerns about ongoing symptoms and social concerns including interference with daily activities and finances (24). Many patients report a disruption of sleeping patterns and a fear that eating certain foods may contribute to the worsening of recurrence of their infection (25). The emotional distress and extreme physical exhaustion associated with CDI creates a traumatic and frightening experience for patients (20).
Outside of their health, CDI has far reaching implications for all aspects of a patient’s life. Patients report that one of the most common symptoms of CDI, watery and uncontrollable diarrhea, has a profound impact on their daily lives (20). One study reports that close to 95% of individuals living with CDI admit that their daily activities are impacted by the infection; in former CDI patients, the number is close to 65% (25). CDI prevents patients from participating in social activities (20) and impairs their ability to do work, resulting in missed days of work and reduced productivity (26). In a recent 2020 study, almost half of participants with active CDI stopped working while actively infected (25). This influence on multiple aspects of patient’s lives reveals just how significant the impact of having or recovering from a CDI can be. Even after recovery from C. difficile infection, patients report consistent worry and fear of recurrent episodes (20) and struggle with psychological and physical symptoms (20, 25), indicating the persistence of the impact of CDI.
Mental health, COVID-19 and CDI
Evidently, rates of depression, anxiety, reported stress, and other psychological disorders are on the rise due to the global COVID-19 pandemic (27-30). With this in mind, it is even more crucial to take care of your mental health. To learn more about the implications of COVID-19 on CDI, check out our module on COVID-19 here.
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References
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