Psychiatrists need to understand the patient’s cancer diagnosis, staging, treatments and their adverse effects, and prognosis to appreciate the challenges the patient is coping with throughout treatment as well as survivorship or end-of-life.
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SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST
Over 15.5 million cancer survivors are alive today in the US, which is similar to the populations of New York City, Los Angeles, and Chicago combined. The number of survivors continues to grow, not just because of earlier detection and treatment, but because of revolutionary new therapies that have been emerging over the past decade. Now, patients with poor-prognosis metastatic cancers such as lung cancer and melanoma can live many years with good quality of life while on active treatment. For many individuals, this changes the landscape from a terminal illness to more of a chronic illness.
Concurrent with advances in cancer treatment, the importance of psychosocial care of individuals with cancer is being increasingly recognized. In 2008, the Institute of Medicine published Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, which documented under-detection and failure to optimally manage psychiatric disorders and psychosocial needs in patients with cancer and their families.1 Unmet needs can have negative consequences for quality of life, treatment adherence, and survival. Subsequently, the American College of Surgeons Commission on Cancer started requiring cancer centers to screen patients for psychosocial distress as part of accreditation, and the American Society of Clinical Oncology developed practice guidelines for managing depression and anxiety.
Although most cancer centers provide some psychosocial services, increased attention to the psychosocial needs of patients with cancer may result in increased referrals to mental health professionals in other settings. Some basic knowledge about a patient’s cancer and treatment are essential for psychiatric management.
Studies have documented that a cancer diagnosis results in high levels of emotional distress.2,3 Patients go through an adjustment period for about 4 to 6 weeks after diagnosis. Cancer for many patients is synonymous with death and debilitating treatments, with images of a prolonged painful dying process. Patients often say they feel overwhelmed trying to assimilate medical information and make treatment decisions-all while continuing to manage family, work, and other responsibilities. However, for the majority of patients, once they receive a plan of action and begin treatment, their emotions tend to level out. Yet, cancer should not be considered as one discrete crisis, but rather as a series of crises that may occur at any time in the disease trajectory from diagnosis, treatment, cycles of recurrences and remissions, post-treatment, and sometimes palliative care.
Mini Quiz, Depression and Cancer
In terms of psychiatric disorders among cancer patients, there is significant variability in the prevalence rates reported due to different assessment methods (clinical interview versus standardized measures), diagnostic criteria, type of cancer, and stage of disease among other variables. Recently, Mehnert and colleagues4 reported a 31% prevalence rate for any psychiatric disorder in cancer patients. Adjustment disorders tend to be the most commonly diagnosed, with the rates ranging from 11% to 35%.5 Rates for depression vary from 11% to 37%, and anxiety disorders show rates from 2.6% to 19.4%.5-7 The rate for depression in the general population is 7%-and thus lower than among cancer patients-but the rates for overall anxiety disorders seem to be comparable.
Assessment and treatment
The Case Vignette presents specific issues important for psychiatrists to consider when treating patients with cancer.
Mrs. T is a 53-year-old postmenopausal married woman with 2 teenage daughters who recently received a diagnosis of stage IV breast cancer metastatic to pelvic bone. Up until 2 months ago, she had been working full-time as an attorney but had to stop because of severe pain that progressively worsened. A medical workup showed an estrogen and progesterone receptor–positive, human epidermal growth factor receptor 2 (HER2)-negative tumor. She was treated with local pelvic bone radiation to help manage the pain, tamoxifen, and zoledronic acid. She was reluctant to take pain medications because of fear of addiction.
She does not have a psychiatric history or comorbid illnesses. Soon after starting tamoxifen, she began to feel very sad, anxious, irritable, and fatigued; cried easily; and had trouble sleeping because of hot flashes. She ruminates on dying and leaving her daughters. She denies hopelessness and suicidal ideation, and quite the contrary she very much wants to live.
Coordinating with the oncology team. With the patient’s permission, consulting and informing the oncology team of your involvement is critical. As mentioned earlier, psychiatrists need to understand the patient’s cancer diagnosis, staging, treatments, adverse effects of treatment, and prognosis to appreciate the challenges the patient is coping with throughout treatment as well as survivorship or end-of-life. Medical concerns can cause or exacerbate depression and anxiety. For example, in this case, knowing that survival with metastatic breast cancer can be years is critical in providing psychiatric care for the patient. Remaining silent as the patient expresses fear of death within the next few months can be taken by the patient as agreement and can exacerbate anxiety. Psychiatrists contribute to oncology care by providing information to the oncology team regarding the patient’s emotional status and potential barriers to care and treatment adherence.
Pharmacotherapy. While there may be overlap between symptoms of depression and anxiety and cancer- and treatment-related adverse effects (fatigue, changes in sleep and appetite), treatment of the psychiatric disorder is primary rather than a focus on differentiating the causes of the symptoms. The most prescribed antidepressants in cancer patients are SSRIs, particularly escitalopram and sertraline, because of their tolerability, few drug-drug interactions (no significant inhibition of cytochrome P450 [CYP450] enzymes), and minimal discontinuation syndrome.6,8 At times the choice of an antidepressant is made based on the antidepressant adverse-effect profile. For example, mirtazapine can be sedating and cause increased appetite, which may be helpful for the cancer patient with insomnia, loss of appetite, and weight loss.
Some psychiatric medications may adversely affect the efficacy of commonly used systemic cancer therapies. Although the full clinical significance is still unclear, some SSRIs may interfere with tamoxifen being metabolized into its active metabolite, endoxifen, through inhibition of CYP2D6. Venlafaxine may be a good option in this situation, especially with evidence that it reduces hot flashes, another adverse effect of treatment.
Be aware that some systemic cancer treatments are associated with psychiatric adverse effects. Vincristine and vinblastine, used to treat leukemia and some lymphomas, may cause depression. Interferon at high doses can cause depression and even suicidal ideation. The chemotherapy agent procarbazine at high doses can cause lethargy, depression, mania, confusion, and hallucinations. It crosses the blood-brain barrier and acts as a monoamine oxidase inhibitor, so it can potentiate the effects of alcohol, opioids, and tricyclic antidepressants. Glucocorticosteroids such as prednisone and dexamethasone are widely used in cancer care. They can cause a range of psychiatric symptoms, from emotional lability, depression, anxiety, restlessness, irritability, and insomnia to paranoia, delusions, and hallucinations. Symptoms may develop within a couple of days of the start of treatment and are also common if the dose is rapidly tapered off. But psychiatric symptoms can develop even on a stable dose.
Pain management. Suffering from uncontrollable pain is one of the most common fears of cancer patients. Unfortunately, pain is under-recognized and undertreated in patients with cancer. Bone pain experienced by cancer patients can be excruciating, and explaining to the patient that at times she may need to use opioids under the care of her oncologist without fearing addiction can prevent the patient from suffering unnecessarily. Poorly managed pain can lead to depression and anxiety. Once pain is appropriately managed, depressive and anxiety symptoms often diminish or resolve.
While some psychiatrists and oncologists have expertise in pain management, others may not and are reluctant to prescribe the necessary medications at the appropriate doses. Speaking with the oncology team and helping to get appropriate referral to a cancer pain specialist or palliative care team is crucial to the quality of life of cancer patients, especially those with advanced disease.
Before the patient’s visit with the pain specialist, it is helpful for the psychiatrist to provide education and correct some common misconceptions. The following 3 key issues should be considered regarding referral for pain management:
1) A majority of cancer patients do not have a history of addiction and actually fear becoming addicted to pain medications
2) Patients view the taking of pain medications as associated with death and dying: “Only a patient who is dying takes morphine”
3) Patients may need education on the difference between addiction and tolerance, in order to comply with prescribed pain medications
The traditional paradigm for psychiatric treatment may require a more flexible approach to scheduling to adjust to the reality of the patient’s needs during treatment. Patients may initially need more frequent appointments as they are adjusting to the diagnosis. New patients may be unsure when to make follow-up appointments because they have many upcoming oncology visits. Letting the patient know that scheduling psychiatry visits shortly after the oncology visits provides an opportunity to review the new medical information during the session.
During treatment, patients may need to cancel or reschedule appointments because of the adverse effects of treatment. Depending on the specific patient’s clinical situation, exceptions may need to be made to policies about late cancellations and no-shows. As the disease advances, patients may become hospitalized and are too weak to make office visits. Accommodating shorter inpatient visits may be indicated for continuity of care.
Patients often include their family in oncology visits, and some assume that this practice also occurs in psychiatric visits. Psychiatrists in cancer centers frequently see patients with their family members in the room. It would not have been out of the ordinary for Mrs. T to have her husband or another family member join her for her psychiatric evaluation. Providing effective support and treatment of patients with cancer will often entail providing support and education to their spouses, children, and significant others. Family members may need support in coping with their own concerns and often need education in how best to support the cancer patient.
Cancer care will continue to change over the next several years, sometimes rapidly. While psychiatrists cannot be expected to stay up to date with all of the emerging cancer treatments, they do need to learn about the ones that their patients might be receiving. Many resources are available for learning more about the psychiatric care of individuals with cancer. The American Psychosocial Oncology Society (www.apos-society.org) has published quick reference handbooks on psychosocial care for adults, children, and elderly adults with cancer and produces webinars on particular topics, such as sexual health and cancer.
For further reading
Jacobsen PB, Jim HS. Psychosocial interventions for anxiety and depression in adult cancer patients: achievements and challenges. CA Cancer J Clin. 2008;58:214-230.
Walker J, Hansen CH, Symeonides S, et al. Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical data. Lancet. 2014;1:343-350.
Dr. Pozo-Kaderman is Director of Cancer Support Services at the Sylvester Comprehensive Cancer Center in Miami, FL. Dr. Pirl is Associate Director, Sylvester Comprehensive Cancer Center, and Associate Professor of Psychiatry, Miller School of Medicine, University of Miami, Miami, FL.
The authors report no conflicts of interest concerning the subject matter of this article.
1. Institute of Medicine (US) Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting. In: Adler NE, Page AEK, eds. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: National Academies Press; 2008.
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