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Psychiatric Illness In The Cancer Patient Dr. Tan Shian Ming Consultant Psychiatrist Singapore General Hospital Singapore Aims • Overview of common psychiatric illnesses in cancer patients • Differentiating psychiatric illness from psychological responses • Treatment considerations The Maelstrom Of Emotions Emotional Reactions • Worry • Anger • Apprehension • Guilty • Hopeless/helpless Psychiatric Disorders • Major Depressive Disorder • Anxiety disorders • Delirium • Neurocognitive disorders/dementia Myth Debunked While emotional responses are to be expected, it is wrong to assume that cancer patients should be “rightfully depressed or anxious” Emotional Reactions vs. Psychiatric Disorders – Why Differentiate? Implications Of Untreated Psychiatric Illness • Increased mortality • Suicide • Prognosis of cancer – mediated by an alteration in the cellular immune response and a decrease in natural killer cell activity • Morbidity/negative impact on quality of life Implications Of False Positive Diagnosis • Unnecessary treatment • Side effects of treatment • Stigma • Cost Major Depressive Disorder Major Depressive Disorder Physical Symptoms • Tiredness/fatigue • Sleep disturbance • GI disturbance • Psychomotor changes Emotional Symptoms • Depressed/low mood • Loss of interest • Concentration difficulties • Guilt/worthlessness • Suicidal ideation Depression Or Sadness? Physical Symptoms Of Depression • In patients with cancer, physical symptoms must be carefully evaluated to clarify their aetiology • Can be caused by the cancer itself or its treatment, not always due to depression Loss of appetite – chemotherapy or depression? Fatigue – complications of cancer or depression? Lack of sleep – unrelieved pain or depression? • Important not to rely on checklist approach Depression Or Sadness? Emotional Symptoms Of Depression • Due to limitations of physical symptoms of depression, need to rest diagnosis more upon the other psychological or "cognitive” symptoms • Loss of interest Normal sadness: react positively to activities that they enjoy, even though the range of activities available to them may be diminished. Some patients with far advanced disease experience heightened pleasure in intimacies with family or friends knowing that the experiences are among the last they might have Depression: fails to brighten with most, if not all, pleasures Depression Or Sadness? Emotional Symptoms Of Depression • Hopelessness Normal sadness: feelings of hopelessness in dying patients who have no hope for recovery; still able to maintain hope that life can be extended, symptoms can be controlled, and/or quality of life can be maintained Depression: hopelessness is pervasive and accompanied by a sense of despair or despondency • Guilt Normal sadness: feel they are burdening their families unfairly, causing them great pain and inconvenience Depression: feel that their life has never had any worth, or that they are being punished for evil things they have done For The Busy Clinician… Management Collaborative Care • Aka integrated care • Usually includes a primary care clinician, a case manager and a mental health specialist (e.g. psychiatrist) Pharmacologic Therapy • Lack of head to head trials • All antidepressants assumed to be equally effective • Selection of an antidepressant depends upon a number of factors The type of depressive symptoms Current medical problems Side effect profiles Pharmacologic Therapy • Selective serotonin reuptake inhibitors: fluoxetine, escitalopram • Tricyclic antidepressants: amitriptyline, nortriptyline • Others: mirtazapine Non-pharmacologic Therapy • Cognitive-behavioural therapy • Support groups • Art therapy Delirium Delirium • aka Acute Confusional State • Medical emergency • Characterised by disturbed consciousness, cognitive function or perception • Acute onset and fluctuating course • Associated with poor outcomes, high mortality rates • Non-detection rates of 33–66% • Because delirium is associated with an increased risk in mortality, it should always be considered first when a physician confronts a patient with confusion Myth Debunked A common error among medical and nursing staff is to conclude that a new psychological symptom is functional without completely ruling out all possible organic etiologies Management – General Principles 1. Liaise with other physicians 2. Identify and treat underlying cause(s) – usually multifactorial 3. Continuous, frequent monitoring – frequent checking of vitals signs during the night should be avoided unless necessary, as sleep deprivation may worsen delirium 4. Monitor and ensure safety 5. Assess and monitor psychiatric status 6. Psycho-education – patients (tailored to their ability to understand their condition); families; nursing staff Non-pharmacological Management First-line treatment for all patients with delirium Patient • Re-orientation by all who come into contact with patient • No mechanical restraints, early mobilization • Adequate hydration, oral feeding, pain control • Address sensory impairment with visual or hearing aids • Communicate clearly and concisely Non-pharmacological Management Environmental • Limiting room and staff changes • Providing a quiet patient-care setting, with low-level lighting at night • Minimal noise allows an uninterrupted period of sleep at night • Rendering environment less alien by having familiar people and objects present • Bright light therapy from 6 to 10 pm1 Caregivers • Encourage family members to come daily • Use clear instructions and make frequent eye contact with patients 1. Chong MS, Tan KT, Tay L, Wong YM, Ancoli-Israel S. Bright light therapy as part of a multicomponent management program improves sleep and functional outcomes in delirious older hospitalized adults. Clin Interv Aging. 2013; 8: 565 – 72 Pharmacological Indications • Failed non-pharmacological interventions • Symptoms of delirium compromise safety or prevent necessary medical treatment (i.e. those with hyperactive delirium) Pharmacological Antipsychotics • Haloperidol 0.5 – 1 mg BD EPSE, prolonged QTc, torsades de pointes (especially with IV administration) • Olanzapine 2.5 – 5mg OD Sedation, EPSE (less than haloperidol) • Points to note No differences in efficacy or safety among the evaluated treatment methods (1st and 2nd generation antipsychotics) In people with conditions such as Parkinson’s disease or dementia with Lewy bodies, use antipsychotics with caution or not at all Pharmacological Consider short-term (usually 1 week or less) Not to discontinue antipsychotics on the 1st day of improvement as the improvement may just be a normal fluctuation in the delirium Discontinue 7 – 10 days after symptoms resolve Gradual tapering allows time to assess patients, to ensure that delirium has resolved and to avoid rapid rebound of symptoms Pharmacological Benzodiazepines • Can worsen delirium hence used in delirium caused by seizures or withdrawal from alcohol or sedative-hypnotics, Parkinson’s disease, NMS • Short-acting BZDs with no active metabolites e.g. lorazepam, are preferred • Respiratory depression, oversedation and paradoxical excitement