Breast Cancer: What Psychiatrists Need to Know

Cancer treatment demands much of patients. It is important for them to exercise and modify certain behaviors, by staying slim, quitting smoking, minimizing alcohol(Drug information on alcohol) intake, and decreasing stress. They must adhere to difficult treatment regimens, endure pain (especially when there are bone metastases), tolerate changes in their work and home lives, undergo modifications in their sexual relationships, and manage anger from partners and children whose needs are not met. The role of the psychiatrist is to diagnose and treat psychiatric symptoms and disorders and provide appropriate psychotherapy, which might include support, cognitive-behavioral therapy, interpersonal therapy, couples and family work, and group therapy. Coordination of care may also be crucial, especially at times of transition, such as the transition from active treatment to palliative or hospice care.

Psychotherapy can, of course, be provided at various stages of the illness. With any patient, making an accurate diagnosis is essential. Within that framework, the psychiatrist can then help the patient with the treatment and medical issues. Some therapies focus on enhancing morale, and others help the patient search for meaning²⁹ or dignity at the end of life.³⁰ Therapy can be supportive or focused on cognitive-behavioral techniques to reduce intrusive thoughts and behavior, such as checking and feeling for cancer recurrence.

Not all patients request or accept counseling, and pushing for acceptance might not be in the patient's best interest. Psychoeducational groups, group psychotherapy, and support groups have all proved helpful for some patients. Whether such groups help patients live longer is unclear. The data to date have been inconclusive or not yet replicated.^31,32 Having a meeting with husbands or significant others and children can also be quite useful to the patient, as well as to family members.

The selective serotonin reuptake inhibitors are the first antidepressants prescribed since they have few side effects and few drug interactions. Mirtazapine(Drug information on mirtazapine) (Remeron) tends to cause weight gain, and women who are already gaining weight because of corticosteroid therapy or chemotherapy may be unwilling to take it. Mirtazapine is a good agent for cachectic patients who have lost weight and need help with sleep. Venlafaxine (Effexor) and paroxetine(Drug information on paroxetine) (Paxil) have been used for women who have hot flashes after chemotherapy or after discontinuing hormone replacement therapy.^12,33

Bupropion (Wellbutrin) is useful in lethargic patients (but one needs to monitor for seizures and brain tumors), and in patients who are not eating because of cachexia. The tricyclic antidepressants, especially nortriptyline(Drug information on nortriptyline) and desipramine, can be helpful in patients who have neuropathic pain. Psychostimulants are effective as adjuvant treatments for depression. They decrease fatigue and counteract opioidinduced sedation, particularly in terminally ill patients. In patients with bipolar disorder, mood stabilizers and neuroleptics can be continued during cancer treatment. Levels of lithium(Drug information on lithium) must be carefully monitored, especially if there are complications from chemotherapy, such as nausea, vomiting, and diarrhea. For patients who have anxiety that is not a primary manifestation of depression, benzodiazepines are frequently used in the acute setting, such as when patients need to have MRI scans or other tests, as well as during chemotherapy. Patients often need sleep aids to counter the side effects of corticosteroids, chemotherapy agents, and intrusive thoughts and nightmares.

Bupropion (Wellbutrin) is useful in lethargic patients (but one needs to monitor for seizures and brain tumors), and in patients who are not eating because of cachexia. The tricyclic antidepressants, especially nortriptyline and desipramine, can be helpful in patients who have neuropathic pain. Psychostimulants are effective as adjuvant treatments for depression. They decrease fatigue and counteract opioidinduced sedation, particularly in terminally ill patients. In patients with bipolar disorder, mood stabilizers and neuroleptics can be continued during cancer treatment. Levels of lithium must be carefully monitored, especially if there are complications from chemotherapy, such as nausea, vomiting, and diarrhea. For patients who have anxiety that is not a primary manifestation of depression, benzodiazepines are frequently used in the acute setting, such as when patients need to have MRI scans or other tests, as well as during chemotherapy. Patients often need sleep aids to counter the side effects of corticosteroids, chemotherapy agents, and intrusive thoughts and nightmares.

The advent of newer therapies and a better understanding of the underlying biology of breast cancer make this a more hopeful time in breast cancer research. Patients have more options and choices to make in their treatment. At the same time, the psychological challenges of getting and living with breast cancer remain difficult, and many patients and their families need help in managing psychiatric symptoms and disorders. Our oncology colleagues are grateful to psychiatrists who want to work as part of the multidisciplinary teams who take care of patients with breast cancer during the acute and survivorship phases of this disease.