Michelle Riba, MD, MS, DFAPA, FAPM

The past 20 years have seen a burgeoning interest in the interface between psychiatry and cardiology—

. More fellows are seeking training in this subspecialty. Increasing numbers of consultation-liaison faculty are finding careers in working collaboratively with colleagues in cardiology, cardiac surgery, cardiac transplantation, psychology, nursing, social work, pharmacy, and many other disciplines. It has been exciting to see the development of guidelines and pathways to provide integrated and collaborative psychocardiology care in areas such as heart failure, pulmonary artery hypertension, arrhythmias, vascular diseases, and myocardial infarction and to seek earlier intervention that can make sustained behavioral changes and prevent disease, such as in diet, exercise, 

, substance use, stress modification, sleep, etc.

Exploring Integrated and Collaborative Care


Special Report Chair, Michelle Riba, MD, MS

Positivism and Heart Health: Issues for Psychiatrists


Christopher M. Celano, MD, and Jeff C. Huffman, MD

The ABCs of Cardiac Screening and Electrocardiography


Margo C. Funk, MD, MA, and Theodore A. Stern, MD

The Cardiovascular Consequences of Drug Use

Craig J. Beavers, PharmD, FACC, FAHA, FCCP, BCCP, BCPS-AQ Cardiology, CACP


Margo C. Funk, MD, MA, and Junyang Lou, MD, PhD

Treatment Dilemmas in Depression and Coronary Heart Disease


Lawson Wulsin, MD, and Juliana Zambrano, MD

We are seeing these changes in patients across the life cycle. Our colleagues in other medical disciplines are trying to understand and frame this goal from the lens of a public health mandate because 

 At the Academy of Consultation-Liaison Psychiatry, special interest groups in psychocardiology have been well attended, and there are more sessions on psychocardiology topics at our annual meetings and articles in the prestigious journal 

Psychiatry and Heart Disease: The Mind, Brain and Heart

. Lawson Wulsin, MD, wrote: “The current need…follows from the profusion of research…showing how the cardiovascular system and psychological distress are each intimately linked to the central, peripheral, and autonomic nervous systems, the immune system, and limbic-hypothalamic-pituitary-adrenal-gonadotropic axis.”

 One only has to look at the significance and severity of coronavirus disease 2019 on the cardiovascular system and on mental health to appreciate the relevance of psychocardiology.

Many topics fall within the psychocardiology domain. For this Special Report, we have chosen a few of the many important topics and issues, with key leaders presenting information in clinically useful and helpful ways. Understanding the underlying mechanisms of and developing effective treatments/interventions for the cardiovascular system as it relates to psychosocial distress and the nervous system in a bidirectional manner are key.

My sincere appreciation to our wonderful contributors of this special series.

is professor in the Department of Psychiatry and director of the Consultation-Liaison Psychiatry fellowship at the University of Michigan in Ann Arbor; she also is deputy editor in chief emeritus of 

1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. 

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

2. Riba M, Wulsin L, Rubenfire M, Ravindranath D, eds. 

Articles

Understanding and developing treatments for the cardiovascular system and how it relates to psychosocial distress and the nervous system are keys to the future of psychiatry.

The field of psycho-oncology is evolving in important and meaningful ways. Screening for distress in patients with cancer is now a concept that is accepted and expected; how this is achieved, however, may vary. Some countries and cancer centers have a uniform system, whereas other countries and centers—and sometimes even clinics within the same center—allow for autonomy in terms of which scales or instruments are used, frequency of screening, and different protocols for various levels of distress.

The next several years will present challenges and opportunities for psycho-oncology to improve care for our patients. For example, it is important that we determine which evidence-based treatments should be provided to which patients and at which points in their trajectories of care. Similarly, how we provide care is certain to evolve, as it is likely telepsychiatry options will become more prevalent. With COVID-19, we have gained experience with the technology, and insurance companies and governmental payers have become more flexible about how we deliver services to patients. For all fields, and psycho-oncology in particular, this could be a positive aspect to come out of a very difficult time. It will be important for us to study and test various ways to provide needed services in this format.

Likewise, the articles in Part II of this Special Report provide a glimpse into the ways the field is evolving. For instance, Wendy G. Lichtenthal, PhD, and colleagues share insights into meaning-centered psychotherapy; our ability to translate such important work to greater numbers of patients is essential.

Psycho-oncology also has gotten firmly incorporated in fellowship training in consultation-liaison psychiatry. The articles by 

Carey J. Myers, MD, PhD, and Carolina Retamero, MD

, on lessons learned provide opportunities to recognize the importance of framing major psychiatric topics and providing the best care possible.

(WPA) as co-chairs of the WPA Section on Psycho-Oncology and Palliative Care, we recognize that these issues are important for psychiatrists and other mental health clinicians throughout the world. We appreciate that 

 has recognized the importance of bringing these topics to you by leading authors, and we hope this inspires you to learn more. We also thank you, the reader, for your interest in these meaningful clinical topics. And, we thank our patients, who continue to inform and educate us so that we can provide better care.

 is Professor, Department of Psychiatry, and Director, PsychOncology, University of Michigan Rogel Cancer Center, Ann Arbor, MI; she also is Deputy Editor in Chief Emeritus of

 is Professor and Chair of Psychiatry, University of Ferrara, Department of Biomedical and Specialty Surgical Sciences, and Director, University Hospital Psychiatry Unit, S. Anna University Hospital and Health Authorities Ferrara, Italy. They report no conflicts of interest concerning the subject matter of this Special Report.

The next several years will present challenges and opportunities for psycho-oncology to improve care for patients.

Looking to the Future and Improving Patient Care

We are very appreciative of the opportunity to present some excellent articles on the interface between psychiatry and oncology, which we know will be useful to you in your practice.

Jimmie Holland, MD, a pioneer and one of the founders of the field of psycho-oncology, mentored many of us and advocated all of us to study, understand, teach, research and care about, and provide for the emotional and psychological needs of people with cancer. She lived and breathed a biopsychosocial approach in the screening, evaluation, treatment, and management of distress, a sixth vital sign.

The articles in Part I of this Special Report discuss PTSD in cancer, special issues for patients with schizophrenia and cancer, and distress management.

Thanks to Dr Holland and others, if you are interested in learning more and want to get active in this field, there are major organizations, founded by Dr Holland, such as the International Psycho-Oncology Society, founded in 1984 and the American Psychosocial Oncology Society, founded in 1986. Dr Holland also gave us Psycho-Oncology, one of our premier peer-reviewed journals, for which she served as founder and co-editor in chief. Dr Grassi and I were honored and privileged to take over the reins of the World Psychiatric Association Section on Psycho-Oncology and Palliative Care from Dr Holland.

There is an active and very productive Interest Group on Psycho-Oncology within the Academy of Consultation-Liaison Psychiatry (ACLP) organization, with many wonderful presentations highlighted at the annual meetings of ACLP. With increasing numbers of US psychiatry residents choosing fellowship training in consultation-liaison psychiatry, clinical and research rotations, electives, and core lectures on psycho-oncology are part of the curriculum in Residency Review Committee-accredited consultation liaison fellowship programs. More and more medical students are interested in this field, as well.

Dr Holland was the inaugural chair of the Distress Guidelines of the National Comprehensive Cancer Network (NCCN). She played a key role in the development of the Distress Thermometer, which enables patients and clinicians to talk the same language to discuss anxiety, depression and other issues that can be distressing, on a scale of zero-to-10, similar to the way pain is discussed and measured. I (Riba) was humbled to be asked to take over as chair of the NCCN Distress Guidelines after we lost Dr Holland on Christmas Eve 2017. Her imprint on our field and on our profession will be long lasting and for that, we are so grateful.

We know you will find these articles in Part I, and later in Part II, to be stimulating and useful—we hope that the information will help you in your multi-disciplinary work with patients and families. We also encourage you to check out some of the organizations previously listed should you want to get more involved in the journals, NCCN, and other guidelines that are updated regularly and provide cutting-edge information based on evidence-based findings.

 is Professor, Department of Psychiatry, and Director, PsychOncology, University of Michigan Rogel Cancer Center, Ann Arbor, MI; Dr Grassi is Professor and Chair of Psychiatry, University of Ferrara, Department of Biomedical and Specialty Surgical Sciences, and Director, University Hospital Psychiatry Unit, S. Anna University Hospital and Health Authorities Ferrara, Italy. They report no conflicts of interest concerning the subject matter of this Special Report.

Introduction: The Interface Between Psychiatry and Oncology

Patients with depression, anxiety, and other mental health problems are going to need us more ever in the days ahead. Dr Riba is Professor and Associate Chair, University of Michigan Department of Psychiatry; Associate Director, University of Michigan Comprehensive Depression Center; and Deputy Editor in Chief Emeritus, Psychiatric Times. University of Michigan Department of Psychiatry has an excellent resources page on its website: 

Michigan Psychiatry Resources for COVID-19

Michelle Riba, MD, shares her thoughts on the days ahead.

COVID-19: What Lies Ahead in Mental Health?

The recent American Psychiatric Association (APA) annual conference included a powerful debate about the Goldwater Rule. As you may remember, in 1964 

 magazine published an article that provided details of a poll of psychiatrists about whether Senator Goldwater was fit to be President. The Editor of the magazine was sued successfully for libel. The APA’s Principles of Medical Ethics, Section 7, was subsequently added in 1973, stating that it is unethical for psychiatrists to give a professional opinion about public figures whom they have not examined in person, and from whom they have not obtained informed consent to discuss their mental health in public statements.

The current political climate and rhetoric of certain world leaders was one of the fundamental issues that instigated this crowded session. Could psychiatrists be more helpful to the public and media if the Goldwater Rule was modified or even abolished?

The Goldwater Rule is a provocative topic and certainly has gotten a lot of buzz. It’s of special interest to psychiatrists because we naturally think about using our expertise to understand the world around us. But the bigger issue of how we as psychiatrists can be helpful, worldwide, is not in the assessment of the mental state of one or more political leaders, but rather how world events are affecting our patients who come from diverse cultures, countries, religions, nationalities, and sexual orientations; and, how these differences are affecting the therapeutic alliance and therapeutic effectiveness. This is indeed a key issue for us as clinicians-and something we need to collectively talk about.

We are a country of immigrants, so it is no surprise that so many of the patients I see in my practice at the University of Michigan were not born in the US. Similarly, our trainees-medical students, residents, and fellows-are also often first- or second-generation Americans or are here on various visas. Throughout the world, we are witnessing the largest mass migration in history of people to different countries. Also of great importance, but not discussed nearly as much, are the internal dislocations where people are in the same country but have had to leave their homes and cities, even regions, to survive. This is part of the fabric of our work in medicine and psychiatric education, worldwide, and should be of the highest level of importance because it is of the highest level of consequence.

There are daily reports of walls that are potentially going to be built to keep out our neighbors; executive orders for detentions of people who have entered our country; reports of fathers and mothers who have been in the country for years but who are now facing deportation; terror attacks around the world; possible intrusions and meddling by countries into other countries’ elections. The daily morning newscasts are no doubt having an impact on how we think about our safety and security and our relationships with others. Do you remember the old TV game show, “Who Do You Trust?” That’s what it sometimes feels like.

As psychiatrists, how do we listen to and help our patients and trainees understand and deal with these issues as we, ourselves, try to determine the manifest and latent impact of these daily assaults on our psyche? How do we weave the ongoing traumatic events occurring throughout the world . . . by realizing that no one is really safe? Do I worry every time a patient tells me he or she is going to get on an airplane, is going into a skyscraper, is going to a concert, or is planning to run a marathon?

How do we help or problem-solve? How do we address the variances between our patients who are from a different cultural background or religion than ourselves, and how do we help them? Or do we not even address these issues? What can we do to help our trainees who are not settled in their careers because they don’t know what the immigration policies will be? What do we say when they tell us that their relatives will not be able to attend their graduation because of worries that they would not be able to return home?

These are some of the issues that are important to us and to our patients and their families. These are the issues that our students, residents, and fellows are worried about. And they are critical as we try to help understand and seek to evaluate and determine how much of our patients’ problems are medical, societal, political, or economic, and how each of these factors will affect their mental and physical health.

Clearly, these are complex issues. But we are not alone, organizations such as the World Psychiatric Association, the APA, and allied groups of the APA that represent psychiatrists throughout the world can help us better understand the difficulties of people from other countries trying to study, learn, work, and be in loving relationships in this country. Our colleagues from psychiatric societies throughout the world can help educate us and guide us as we determine how to help patients integrate into a different society, without losing themselves.

We must listen and learn from psychiatric colleagues who are perhaps more experienced and knowledgeable about these issues and how these feelings can affect the therapeutic alliance. Being humble and realizing that there are colleagues who can help us is, in my mind, the first step. Asking for advice-both informal as well as formal-is key. Setting up grand rounds, case conferences, and discussions about these topics . . . these are formative steps. Trainees and faculty stepping forward to talk about how these issues may have already had an adverse or a positive impact on patient care would be instructive.

We cannot solve the political problems of the world, but we can help those who are affected by them. We must work together at every level, individually, academically, organizationally, both within our own countries and across national boundaries.

I have had the honor and privilege of serving as an officer of the World Psychiatric Association, Past President of the APA, past Board Member of the Pacific Rim College of Psychiatrists, past Chair of the APA Council on Global Psychiatry, and a faculty member and mentor in the University of Michigan Medical School Global Health and Diversity Track. I know firsthand from these experiences that there is a major organizational level, in addition to the individual and academic levels discussed above, where important contributions to address these issues can occur.

As psychiatrists, these are some of the multitude of questions we must be asking and collectively debating and answering. The Goldwater Rule helped us formulate some ethical boundaries about what psychiatrists could and could not do. Certainly, there is currently a call for us to step up and help determine what is important now and the positive role that we can have with the issues we are facing as we try to optimize the therapeutic alliance and therapeutic effectiveness.

We psychiatrists can't solve the world's political problems, but we can help those who are affected by them. Suggestions here.

Culture, Diversity, and the Therapeutic Alliance: How Can Psychiatrists Contribute to the Discussion?

[[{"type":"media","view_mode":"media_crop","fid":"13610","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_739935661750","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3752","media_crop_rotate":"0","media_crop_scale_h":"125","media_crop_scale_w":"89","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]As a community of mental health professionals, it is time for us to use our resources, experience, and expertise to address a significant public health problem-suicide among college students. Of the 19 million Americans who experience depression each year, many develop their first symptoms 

 Many questions related to this critically important and devastating topic need to be addressed:

• Why do so many undergraduates seriously consider suicide?

• Why are so many college students depressed?

• Is there a way to predict the risk for suicide?

• What can we do to increase resilience and improve outcomes?

Suicide occurs several times a year at many of the major universities, yet often it is kept under wraps. Moreover, student suicide often does NOT receive formal review. Concerns about confidentiality, worries about copycat or contagion, families not wanting others to know are just some of the reasons the suicide is not investigated. In 2007, Eisenberg and colleagues

 reported that 36% of university students who screened positive for depression received services in the past year. However, Drum and colleagues

] found that 46% of undergraduate students with suicidal thoughts chose not to tell anyone. Many at-risk students do not seek help: it may be that they do not recognize that their worries are related to symptoms of depression; they hesitate because of the perceived stigma of asking for help; or they fear possible ramifications on future careers.

No university or college is spared from these tragedies.

 Recent reports of otherwise healthy-looking students illustrate the many faces of this problem-track stars and popular varsity gym- nasts jumping to their deaths, straight A students found hanging in off-campus housing. Stressors that put students at increased risk include bullying, hazing, abuse of alcohol or drugs, examination pressures, and career and job anxieties; veterans who are trying to assimilate back into an academic life are also at increased risk. Combine these with limited availability of services (long wait times at understaffed counseling and psychological services) and easy access to guns, and the consequences are tragic.

There have been murders and murder-suicides by students and former students with mental illness-Virginia Tech; Pima Community College, Tucson; Northern Illinois University; University of Colorado, Aurora-that make us all aware of the enormity and toll of this problem and the difficulty of trying to understand and effect prevention. Expelling the student from school or not addressing the problem while the student is in school carries its own risks.

More and more groups around the country are trying to study this problem and other aspects of college mental health. At the University of Michigan for example, we have had our 12th year of hosting an annual conference on depression on college campuses. Led by John Greden, MD, and Daniel Eisenberg, PhD, colleagues from all over the US and abroad, as well as students, come together to discuss research and novel programs to better serve depressed students.

We are beginning to see social workers and other mental health professionals being hired for athletic departments as well as engineering, law, and business schools. Videos produced at the University of Michigan show varsity athletes who have suffered with depression and eating disorders. The videos are being disseminated to help stimulate conversation among students and hopefully decrease stigma.

 are serving as guideposts for how to best understand and serve this heterogeneous population. The Substance Abuse and Mental Health Services Administration is providing funding for projects regarding alcohol and substance abuse and delivery of mental health services on college campuses. The Academy of Child and Adolescent Psychiatry and the National Network of Depression Centers, among others, are forming committees and task forces to explore ways to recognize students who need help and provide a better transition from high school into college.

Increased attention is being given to providing guidance and information about mental health services to students and their families during freshman orientation. Universities are looking for better ways of funding campus mental health services. New models of linking to clinicians in the community and ideas about training the next generation of clinicians who will provide mental health services for college students are also ongoing initiatives.

There is better integration of mental health with physical health services on campuses, and students are screened for depression, anxiety, sleep disturbances, substance abuse, and eating disorders. Many universities are using online means to help students connect with counselors and other professionals 24-7. And, mobile apps are available for students to self-monitor and check their mood, sleep, etc.

The successes of interventions, such as drop-in mental health groups led by trained clinicians, networking with faculty and residence hall advisors, and flyers and online services and reminders, are demonstrating that we need to provide more outreach directly to students: in their dorms, sororities, and fraternities-even in lecture halls. In addition, opening the doors so that families can be part of their child’s care without being intrusive (sometimes called “helicopter parents”) allows us to hear their worries and concerns and seek their help.

 are doing impressive work to develop Web-based screening, information, and delivery of services to college students through an e-Bridge intervention plan. The concept is that students complete an evaluation at baseline and see information online about availability of services; those students who screen positive receive personalized feedback reports.

These initiatives will likely improve outcomes for students, but much more is needed. We all need to weigh in and help develop a system of cooperative and collaborative services so that students with potential problems can be recognized at an earlier stage without “profiling” or setting them unnecessarily apart from their friends. This is too difficult a task for any one institution to take on. This is a national problem that is going to require our considerable thinking and expertise. There are many potential handoffs along the way, points where we can possibly intervene or better connect with a student so that students do not feel desperate and alone.

It is not just a matter of identifying problems but also of creating a community of students, families, friends, mental health professionals, faculty advisors, and many others to help students gain psychological resiliency from a healthy growth perspective in late adolescence. Prevention is a key component that requires understanding normal development and recognizing where there are risks as well as opportunities for intervention, such as self-management, alcohol and substance abuse minimization and management, improved sleep, reduced stress, and more exercise.

The aim of this editorial is to get the discussion started. In the coming months, we hope to bring you articles by colleagues who are working on various aspects of this problem so that we can all become better educated about what is currently being done and what is still needed. We hope to propel the conversation about this topic. We appreciate and welcome your thoughts and ideas.

Please leave your comments below. Although we are unable to respond to each comment directly, we appreciate your input and will review all the comments.

 University of Michigan Health System. Depression Center. 

 Eisenberg D, Gollust SE, Golberstein E, Hefner JL. Prevalence and correlated of depression, anxiety, and suicidality among university students. 

 Drum DJ, Brownson C, Burton Denmark A, Smith SE. New data on the nature of suicidal crises in college students: shifting the paradigm. 

Mental Health Care in the College Community

 King CA, Eisenberg D, Zheng K, et al. Online suicide risk screening and intervention with college students: a pilot randomized controlled trial. 

College mental health is not just a matter of identifying problems but also of creating a community of students, families, friends, mental health professionals, faculty advisors, and many others to help students gain psychological resiliency.

Suicide in College Students: A Call to Action

This isn’t a review of the book or the movie. There have been, amazingly, over 91,000 published reviews of the book already. Probably no one needs another review, especially by me! Seems like “the whole world,” anyone who has wanted to, has already been through some version of this story. How do I know? I don’t . . . but just try casually bringing up 

 at the next cocktail party or as you are waiting for a meeting, and see the reaction. What I have noticed is that people get animated by this topic. It isn’t the usual-wasn’t that a great book, or I couldn’t wait to finish that book. . . . Rather, there is clear-cut emotion that follows the question about any experience with this story. And many people don’t like the ending, that’s for sure.

I have to admit that I resisted reading the book. My 25-year-old daughter, Erica, cajoled me, wanting to share the “thrilling experience” and thought it would be a page-turner. She also wanted to see the movie with me, and as everyone knows, one should read the book before the movie version comes out.

. I found the book taxing to get through. I don’t particularly like reading one person’s perspective and then the other’s . . . but that is just a personal preference. Seems like some of the current series on television are using this methodology. That would be interesting to discuss; maybe it is a good strategy on a number of levels.

I don’t mind reading books, especially detective stories, in which there are sociopaths, or people with chaotic, disordered minds manifesting cruel or unusual behavior. With that said, I found the 

 protagonists quite annoying and irritating. I kept turning the pages, but it was just to finish the book rather than to savor the story line. And then I saw the movie, which I know I wouldn’t have been able to follow without having read the book.

When I ask friends and colleagues about the book, most of them have really enjoyed it and would love to discuss it with me if I let them . . . but I don’t want to. Many want to discuss the ending and why they think there should have been a different conclusion. Some want to discuss their own emotions as they went through the book. I guess that is a great feat that an author can get us to have such feelings, to get us interested or excited, or very angry or sad.

Some of my non-psychiatrist friends want to find out what I, as a psychiatrist, thought about the protagonists. Do I have patients like this? What do I think was wrong with these folks? I always try to side step these issues because when I read a book, I genuinely try to read for enjoyment and to be a non-professional with works of fiction. It would be interesting to hear what your habits are and your experiences with this book/movie.

So, I am sorry if you wanted an in-depth review of 

. I bet many of you could have done a much better job. Like “everyone” else when it comes to 

, I wanted to let you know how I felt about it.

When I ask friends and colleagues about this book, most of them have really enjoyed it and would love to discuss it with me if I let them . . . but I don’t want to. Here's why.

Gone Girl by Gillian Flynn

As with all medical emergencies, psychiatric emergencies are among the most clinically challenging situations. In our training, we learn how to assess for suicidality, homocidality, and other aspects of dangerousness to self and others. Psychiatric residents have required training in emergency department settings, under close supervision, to prepare them for this important aspect of clinical care. We train our students to think about potential risk factors, such as substance abuse; obtaining a good history of violence; assessment of weapons; and demographic information, such as gender, age, race, psychiatric diagnosis, comorbid medical conditions, pain, and recent loss.

By practice, experience, and didactics, we drill how to recognize danger in our patients; clinical situations in which violence may be acute, such as agitated depression, mood lability, or psychosis with command hallucinations; and certain situations that lend themselves, by their very nature, to potential violence or emergencies, such as suicidal ideation, intent, or plan. In addition, there are medical settings, such as psychiatric and medical emergency departments and inpatient psychiatric units, and certain high-risk patient populations, such as the elderly and those with comorbid medical conditions, in which the risks of emergencies may be greater.

Yet, prediction of violence is difficult and complex. Taking care of patients who may be aggressive, homicidal, or suicidal, requires incredible skill and ability. Making the wrong decision regarding hospitalization or discharge, not obtaining information from family or other sources, and not taking enough time to obtain a careful history all can have life-or-death consequences. How to best enhance clinician safety and manage psychiatric emergencies as well as anticipate potential violence and aggression are key themes in this Special Report.

As with all medical emergencies, psychiatric emergencies are among the most clinically challenging situations.

Enhancing Clinician Safety and Managing Psychiatric Emergencies

One of my patients was recentlylistening to a television programon breast cancer. The oncologiston the program noted that this was thebest time in history to have breast cancerbecause of the exciting new treatments,imaging techniques, improvement insurvival rates, and the appreciation thatbreast cancer is probably a heterogeneousdisease. My patient said this isall great news-but would this help herlive to see her children graduate fromelementary school?

Many of our female patients are more  worried about getting breast cancer than  having cardiovascular disease. Breast  cancer is so common that almost everyone  reading this article will eventually  know someone with this disease, whether  it is a family member, close friend,  colleague, or neighbor. It may even  strike one of us. For a session at the  upcoming American Psychiatric Association  annual meeting in Toronto, we  asked some of our colleagues to talk  about their own experiences with cancer.  Three of the panel members have themselves  survived breast cancer.  

Why are we so terrified of breast  cancer? The disease interweaves  complicated emotional, physical,  genetic, and cosmetic factors. As practicing  psychiatrists, it is almost certain  that we will, at some point, care for  patients who are receiving treatment for,  or who have a history of, breast cancer.  In this article, we review some of the  major issues for psychiatrists to  consider. Men, of course, may also get  breast cancer, but in much smaller  numbers. Consequently, we will focus  solely on breast cancer in women.  

Breast cancer is the most commonly  diagnosed cancer in women and  accounts for approximately 15% of all  cancer deaths in the United States.

 In  2005 alone, an estimated 211,000  women received a diagnosis of breast  cancer

 and an estimated 40,000 died of  the disease.

 Let's look at several aspects  of breast cancer and its treatment.  An estimated 5% to 10 % of women  with breast cancer have an inherited  mutation in a cancer susceptibility gene.

  Mutations in the BRCA1 and BRCA2  genes account for most of these cases.

  As a result, women who know they carry  these mutations probably understand  that their lifetime risk of breast cancer  is as high as 85%.

In certain families, multiple femalerelatives receive a diagnosis of breastcancer, sometimes at an early age, despitethe absence of mutations in the 

 genes. These malignanciesappear to be more genetically heterogeneousthan those associated with the

Depending on a patient's particularcircumstances, breast cancer treatmentmay include surgery, radiotherapy,chemotherapy, or hormonal therapy.These treatment modalities haveimproved outcomes in patients with breastcancer. When breast cancer metastasizes,however, survival is limited.

 More thanhalf of women with metastatic breastcancer, for example, have hepatic involvement,which makes treatment even moredifficult.

 And while sentinel-nodemapping helps reduce the risk of unsightly or disabling lymphedema, it does noteliminate this condition.

Important new findings about theepidermal growth factor receptorHER2, which plays a crucial role in theregulation of cell proliferation andsurvival, are changing breast cancertreatment. Overexpression of HER2correlates strongly with poorer prognosisin breast cancer. Use of anti-HER2agents, such as trastuzumab, or combiningHER2 blockers with other agentsmay overcome the tumor's compensatoryor resistance mechanisms, therebyincreasing the efficacy of anti-HER2therapies. The bottom line is that oncologistscan correlate HER2 findingswith tumor resistance to chemotherapyand make better predictions. This helpstailor therapies and treatment for individualpatients.

Although modern breast cancer treatmentshave led to improved patientoutcomes, they are also associated withsubstantial adverse effects.

 Chemotherapywith alkylating agents can causealopecia, ovarian failure, prematuremenopause, and weight gain. Taxanes(eg, paclitaxel, docetaxel) can causepainful and disabling peripheral neuropathy.Antiestrogen therapy, includingtreatment with agents such as tamoxifen,raloxifene, anastrozole, and exemestane,is administered for severalyears and can cause insomnia, hot flashes, irritability, and depression insome women.

 At the end of activetreatment, psychological distress iscommon. Patients are often frightenedand vulnerable and feel less protectedwhen they are not seen frequently andregularly by their oncologist.

As psychiatrists, certain aspects of this  discussion immediately draw our attention.  We anticipate that patients will  experience anxiety about genetic testing  or about being in a family whose  members have the 

  gene. Post-traumatic issues may accompany  the diagnosis, the mastectomy, or  chemotherapy. Anxiety and depression  may occur if metastatic disease develops,  especially in the liver or brain. Space  does not allow for a comprehensive review, but we can outline some of themajor issues pertaining to breast cancertreatment and psychiatric symptoms anddisorders.

The percentage of women receivingadjuvant chemotherapy for breastcancer could be greater than 80%depending on age, stage, and receptorand node status.

 Depression iscommonly diagnosed after treatmentof breast cancer, with reported ratesranging from 3% to 55%.

Postchemotherapy cognitive disordersinclude disturbances of consciousness,executive functioning, aphasia,apraxia, and agnosia.

 About 20% to38% of women who receive a diagnosisof breast cancer experience highlevels of psychological distress duringthe first year after diagnosis.

 Forsome patients, high levels of intrusivethoughts and avoidance may persist foryears after the initial diagnosis.

Prevalence rates of depression inwomen with breast cancer range from1.5% to 46%.

 Depression rates reflectmany factors, including:

Type of surgery (lumpectomy,  partial mastectomy, or mastectomy).

Opportunities for the patient to make choices and participate in treatment.

Type of therapy (radiation, chemotherapy).

Whether the study was short-term or long-term.

Whether the patient has a history of depression.

The treatments and/or the canceritself have an impact on anxiety, sexualsatisfaction, sleep, quality of life, self image,and body image. Some patientsfeel traumatized and mutilated and mayregret having certain types of surgery,especially prophylactic bilateral mastectomies.The psychological impact ofbreast cancer also affects spouses, partners,children, and parents of womenwith breast cancer.

The good news is that in addition tothe most widely prescribed anticancerdrug in the world, tamoxifen, neweragents, such as aromatase inhibitors,are demonstrating important benefitsin large randomized trials. A betterunderstanding of the role of biologicmarkers, such as HER2, is givingwomen and their physicians the opportunityto see sooner whether chemotherapyis helpful.

The psychiatrist can be a key memberof the treatment team at almost everystage-from the time a woman goes fora screening mammogram to the time ofdiagnosis, treatment, surveillance,survivorship, recurrence, and palliation.Important psychiatric issues may ariseat each point.

Breast cancer is a complex, heterogeneous  disease. You should not extrapolate  from one patient to another,  especially if you do not have large  numbers of women with breast cancer  in your care. It is important to focus on  the specific patient's age, stage, and type  of breast cancer (ductal, lobular, etc) and  the recommendations of her oncologist.  The patient often has difficult choices  and decisions to make.

As psychiatrists, our role is to treatthe patient for underlying anxiety,depression, adjustment issues, obsessions,and other problems so that shecan make the best possible decisions.Although we are not oncologists, weneed to have a good understanding ofthe treatments available to our patients,as well as the possible adverse reactionsto and implications of these treatments.For example, a patient for whom amastectomy is recommended in preferenceto a lumpectomy might have todecide between immediate and delayed reconstructive surgery. Consider the caseof a woman with a significant familyhistory of breast, ovarian, and coloncancer who has just received a diagnosisof breast cancer requiring a mastectomy.As a prophylactic measure, shemight think about having her other breastremoved along with both ovaries. Herpsychiatrist might be interested in helpingher think through the implicationsfor her body image, sexuality, having 1versus 2 mastectomies, the recoveryperiod, and related issues. Dependingon the woman's age, partner status, andchildbearing status, couples therapymight also be indicated. Referral to afertility clinic or information about eggbanking may also be helpful to thecouple.

It is very important for the psychiatristto share the psychiatric evaluationwith the oncology team and to receivecopies of ongoing treatment notes fromthe medical team. Most oncologists aregood at dictating their follow-up andinterval notes to all physician membersof the team, because it is so importantfor information to be current and usableby all members of the team. The psychiatristmust be sure to be part of this teamand to receive these notes. While itmight be inappropriate for the psychiatristto reveal the specifics of psychotherapysessions to other members ofthe team, it is important for other treatingphysicians to know about anypsychotropic medications prescribed;significant issues that might affect theoncologic treatment; and other issuesspecific to that patient.

Breast cancer is so prevalent thatpsychiatrists should reflect on the countertransferenceand transference issuesthat occur during treatment. Many ofus have our own family or friends whohave suffered with breast cancer. Weneed to be aware of these factors andour feelings about them as we try tohelp our patients. Further, patients oftenidealize or devalue certain members oftheir oncology teams, especially if thediagnosis was delayed or if a misdiagnosisoccurred. We are sometimespresented with patients who areinvolved in malpractice litigation. Weneed to help the patient manage thesedifficult tasks and feelings while simultaneouslyattending to ongoing oncologictreatment.

The long-term risk of the onset ofdepressive symptoms after a medicaldiagnosis is becoming clear.

 Subjectsin the Health and Retirement Study,which included 8387 adults aged 51 to62 years, had no significant depressivesymptoms at baseline in 1992. Theywere monitored from 1994 to 2000.Patients who received a cancer diagnosisduring follow-up had the highestrisk of depressive symptoms, followedby patients with chronic lung disease and heart disease. Screening for depressionin patients with cancer is a highpriority for clinical care and researchfor psychiatrists.

Practicing oncologists often complainabout the difficulty of making a referralto a psychiatrist. Because of thecomplexity of psychiatric insurance, itis often very hard to make a referral whilea patient is in an oncologist's office. Ifpsychiatrists could develop better andeasier ways for other physicians to makereferrals, such as accepting fax referralsand improving callback times, the overallsystem of care might improve andpatients would see psychiatrists sooner.

While breast cancer screening bymammography has been shown toreduce breast cancer mortality,

 mammographic screening has potentiallyadverse psychological effects.Possible problems include induced anxiety,worry or concern about gettingbreast cancer, transient anxiety experiencedwhile undergoing an unfamiliarmedical procedure, and severe anxietysymptomatic of psychiatric morbidity.

Women with a family history ofbreast cancer are at increased risk forthe disease

 and have high levels ofcancer-specific anxiety.

 As a result,the psychiatrist must obtain a goodmedical and family history to ascertainhow important this type of anxiety is forthe patient and how best to manage it, whether by medication, psychotherapy,or education.

Cancer treatment demands much ofpatients. It is important for them to exerciseand modify certain behaviors, bystaying slim, quitting smoking, minimizingalcohol intake, and decreasingstress. They must adhere to difficult treatmentregimens, endure pain (especiallywhen there are bone metastases), toleratechanges in their work and home lives,undergo modifications in their sexualrelationships, and manage anger frompartners and children whose needs arenot met. The role of the psychiatrist isto diagnose and treat psychiatric symptomsand disorders and provide appropriatepsychotherapy, which mightinclude support, cognitive-behavioraltherapy, interpersonal therapy, couplesand family work, and group therapy.Coordination of care may also be crucial,especially at times of transition, such asthe transition from active treatment topalliative 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 meaning

 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 acceptcounseling, and pushing for acceptancemight not be in the patient's best interest.Psychoeducational groups, grouppsychotherapy, and support groups haveall proved helpful for some patients.Whether such groups help patients livelonger is unclear. The data to date havebeen inconclusive or not yet replicated.

 Having a meeting withhusbands or significant others and childrencan also be quite useful to thepatient, as well as to family members.

The selective serotonin reuptakeinhibitors are the first antidepressantsprescribed since they have few sideeffects and few drug interactions.Mirtazapine (Remeron) tends to causeweight gain, and women who are alreadygaining weight because of corticosteroidtherapy or chemotherapy may be unwillingto take it. Mirtazapine is a good agentfor cachectic patients who have lostweight and need help with sleep.Venlafaxine (Effexor) and paroxetine(Paxil) have been used for women whohave hot flashes after chemotherapy or after discontinuing hormone replacementtherapy.

Bupropion (Wellbutrin) is useful inlethargic patients (but one needs tomonitor for seizures and brain tumors),and in patients who are not eatingbecause of cachexia. The tricyclic antidepressants,especially nortriptyline anddesipramine, can be helpful in patientswho have neuropathic pain. Psychostimulantsare effective as adjuvanttreatments for depression. They decreasefatigue and counteract opioidinducedsedation, particularly interminally ill patients. In patients withbipolar disorder, mood stabilizers andneuroleptics can be continued duringcancer treatment. Levels of lithium mustbe carefully monitored, especially ifthere are complications from chemotherapy,such as nausea, vomiting, anddiarrhea. For patients who have anxietythat is not a primary manifestationof depression, benzodiazepines arefrequently used in the acute setting, suchas when patients need to have MRI scansor other tests, as well as duringchemotherapy. Patients often need sleepaids to counter the side effects of corticosteroids,chemotherapy agents, andintrusive thoughts and nightmares.

The advent of newer therapies anda better understanding of the underlyingbiology of breast cancer make thisa more hopeful time in breast cancerresearch. Patients have more optionsand choices to make in their treatment.At the same time, the psychologicalchallenges of getting and living withbreast cancer remain difficult, andmany patients and their families needhelp in managing psychiatric symptomsand disorders. Our oncologycolleagues are grateful to psychiatristswho want to work as part of the multidisciplinaryteams who take care ofpatients with breast cancer during theacute and survivorship phases of thisdisease.

Dr Riba is director of the psycho-oncologyprogram at the University of Michigan, in AnnArbor Comprehensive Cancer Center and professorand associate chair for IntegratedMedicine and Psychiatric Services in the departmentof psychiatry at the University ofMichigan. She has been a consultant for EliLilly, Pfizer, and GlaxoSmithKline.

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 Phillips KA. Current perspectives on BRCA1- andBRCA2-associated breast cancers. 

 Peshkin BN, Isaacs C. Evaluation and managementof women with BRCA1/2 mutations. 

 King MC, Rowell S, Love SM. Inherited breastand ovarian cancer. What are the risks? What arethe choices? 

 Hall JM, Lee MK, Newman B, et al. Linkage ofearly-onset familial breast cancer to chromosome17q21. 

 Narod SA, Foulkes WD. BRCA1 and BRCA2: 1994and beyond. 

 Podnos YD, Wagman LD. Surgical managementof hepatic breast cancer metastases. 

 Jardines L, Callans LS, Torosian MH. Recurrentbreast cancer: presentation, diagnosis, and treatment.  

Many of our female patients are more worried about breast cancer than heart disease. Because psychiatrists will almost certainly care for patients who  have a history of breast cancer, Dr Riba reviews some of the major issues  to consider.

Breast Cancer: What Psychiatrists Need to Know

There is no question that psychotherapy and psychopharmacology can be successfully integrated. Indeed, there are still many psychiatrists left in this country who talk to patients and families, provide both psychotherapy and psychopharmacology, and care for patients in a biopsychosocial context.

The real issues that vex our field concern the practice of split treatment. Can psychotherapy and psychopharmacology really be integrated when provided in our current health care model, which emphasizes split treatment? What are the implicit and explicit problems and opportunities? This discussion will provide some of the background regarding the forces that have fueled split treatment and suggestions that could promote more integration of services within a split-treatment model.

Freida Fromm-Reichmann, M.D., (1947) was one of the first to describe what has now come to be called "split treatment," wherein a therapist provides the psychotherapy and a physician provides the medical care. Over the last 50 years, there have been a number of terms used in the literature to describe and extend the definition of this practice (e.g., divided treatment, integrated treatment, combined treatment, split treatment). Many of these terms seem contrary to one another, leading to confusing terminology, to say the least. The confusion lies, to some extent, in the integrated treatment. There are those who view split treatment as integrated, in that the patient is receiving both pharmacotherapy and psychotherapy, albeit from more than one clinician. The issue is not how many clinicians are providing these treatments, but that the patient is receiving several modalities of treatment. Since the field has not universally adopted standard definitions, we will use integrated treatment to describe the practice wherein the psychiatrist provides both the psychotherapy and pharmacotherapy (Kay, 2001) and split treatment when the therapy and pharmacotherapy are provided by separate practitioners.

While there has been increasing evidence that a combination of psychotherapy and pharmacotherapy is best for patients with certain disorders (e.g., major depression), the controversies have revolved around whether care should be provided in split or integrated treatment, and how the pharmacotherapy and psychotherapy should be sequenced in both of these practice patterns (Roose, 2001). Further, are patients with certain types of disorders, such as borderline personality disorder, best treated in integrated or split treatment (Silk, 1999)? What are the economic advantages/disadvantages for split versus integrated treatment?

There have been multiple political, administrative, educational and economic factors that have led more psychiatrists to provide care in a split treatment modality (Dewan, 1999) (Table 1). Duffy et al. (2001) have presented data from the American Psychiatric Association's Psychiatric Research Network (PRN) demonstrating that outpatients with mood disorders (especially those with bipolar disorder) who are seen by younger, board-certified psychiatrists practicing under utilization management in clinic/hospital-based practices are more likely to be seen in split treatment arrangements.

One of the few studies that looked at the economics of integrated versus split treatment was completed by Goldman et al. (1998). This study showed that, in fact, it might be less expensive for psychiatrists to provide integrated care than split treatment, mostly because patients are seen fewer times in integrated care and achieve the same endpoint.

Balon (2001) has described the various arguments for and against split treatment. Positive aspects include: the use of special talents of therapists and psychiatrists; cost-effective use of all available resources; increased time and resources available for patients; an increased amount of clinical information; more opportunity for patients to select a therapist with an ethnic background similar to theirs; enhanced patient compliance; and professional and emotional support for both therapists and psychiatrists. Negative aspects include: inappropriate prescribing decision without knowledge of the content of therapy; potentially discrepant information given by a patient to each of the treating parties; splitting of the treating parties; unclear confidentiality; clouded legal and clinical responsibility; therapist, psychiatrist and patient misperceptions; and no reimbursement for collaboration.

Unfortunately, many of these aspects are not actually determined ahead of time for patients. In other words, when a patient calls a residency training clinic, a community mental health center or managed behavioral health care triage number requesting mental health services, there are often systems issues that cause a patient to see a psychiatrist first, rather than a non-physician clinician. Very often, it has to do simply with which clinician has the next available slot (most likely, a non-physician) or whether the patient is having acute symptoms (more likely, a physician slot). If a patient first sees a non-physician clinician, then that person will decide whether the patient will be further evaluated for medications. If the patient is first seen by a physician, then it will be up to the physician to decide if they will also provide psychotherapy or will refer the patient to another clinician for psychotherapy.

If this sounds complicated, it is. A case in point:

Ms. J is a 44-year-old divorced woman with no previous psychiatric or medical history. Her youngest child is moving back home and is causing Ms. J to have to adjust to a new schedule and new issues. She becomes depressed and irritable. Ms. J's friend suggests that she get help. Should Ms. J see her primary care physician? Should she call her health benefits coordinator and see the first available clinician? With her history, which type of clinician will be assigned--a social worker, psychologist or psychiatrist?

One of the problems for patients is deciding who is in charge. Who should they see for which problems? What is occurring within the doctor-patient relationship? Complaints that seem like side effects of medications may be physical side effects or possibly resistance to taking medications. Patients often do not know who to call in emergencies; who to call when one clinician is on vacation; and what to do if there are transferential difficulties arising in the different relationships with clinicians.

Similarly, clinicians often do not work out communication patterns that lead to successful split treatment arrangements or articulate the implicit and explicit responsibilities of the clinicians (e.g., as in a contract for services) (Appelbaum, 1991). At the beginning of split treatment, clinicians often do not discuss how to manage various issues (e.g., talking with the family; use of mental health insurance benefits; treatment planning; and coverage) and often find themselves in legal and ethical quagmires (Lazarus, 2001; Macbeth, 2001).

It is critical that clinicians and patients understand the pitfalls and problems inherent in a split treatment arrangement. Unless the clinicians are working in a contained, well-organized setting (e.g., an outpatient resident clinic) where the clinicians see one another regularly and have computer-based charts available to all clinicians, much planning and thought must go into providing effective and safe split treatment. As with any treatment planning, clinicians--along with the patient--must think about the care with a beginning, middle and end. Table 2 lists some suggested guideposts of issues that must be discussed between clinicians and patients when in split treatment arrangements (Rand, 1999; Tasman and Riba, 2000).

Providing split treatment actually requires better psychotherapy skills than integrated treatment. It is actually more complex to manage the care that two clinicians are providing than if you are doing it yourself. The doctor-patient relationship is disrupted in a split treatment arrangement (Tasman et al., 2000). As Smith (1989) said, "In contemporary treatment situations that include a patient, a therapist, a pharmacotherapist, and a pill, the transference issues can become more complex than the landing patterns of airplanes at an overcrowded airport."