Management of psychiatric disorders in patients with cancer

Abstract

Psychiatric disorders are seen at an increasing rate in those diagnosed with cancer. The most common psychiatric disorders that are seen are delirium, depression, adjustment disorders, anxiety, sexual dysfunctions, and sleep disorders, which overall affect 30%–40% of people diagnosed with cancer. The incidence of psychiatric disorders among those in an advanced phase of cancer illness is higher. However, psychiatric disorders are underdiagnosed and under-treated and affect quality of life (QoL) of a person with cancer. The advancement in psychopharmacology, availability of newer and better tolerated drugs with lesser side effect profile has been a boon in the field of clinical psycho-oncology. There has been growing evidence for the use of nonpharmacological interventions in reducing distress and treating psychiatric disorders. Hence, psycho-oncology is becoming a specialized novel area, integrating psychiatry, psychology into the care of oncology. The definition and various aspects of psycho-oncology have been covered in different chapters of a recent book on psycho-oncology.[1] Here, we focus on the most common psychiatric disorders, their assessment, and their treatment focusing on the pharmacological and nonpharmacological aspects. We have looked at literature and guidelines from various countries and made a comprehensive summary of all, which can start as the beginning point for formal guidelines for the Indian setting. These guidelines will enable standard care and uniformity in procedures and practices across hospitals in the country. This is in the hope of also intriguing clinicians and researchers to focus on specific areas of psycho-oncology and develop the guidelines further. In the first part of the chapter, we cover some basics and key areas of pharmacological management in psycho-oncology. The general principles of pharmacological management in Box 1, interaction of anticancer drugs (ACD) and psychotropics in Table 1, anticancer medications induced psychiatric issues in Table 2 and a list of anticancer drugs with no known interactions with psychotropics in Box 2.Box 1: General principles of pharmacological management in psycho-oncologyTable 1: Drug interactions of psychotropics and anticancer medicationsTable 2: Anticancer medication induces psychiatric disorders and their managementBox 2: Anticancer drugs that do not have any known interactions with psychotropicsAt this stage, we have understood some pharmacological aspects of psycho-oncology. Now, we will look at the nuances in the assessment and treatment of individual psychiatric disorders with respect to psycho-oncology. DEPRESSIVE DISORDERS Introduction In cancer patients, depression is one of the most commonly diagnosed psychiatric disorders.[2] The incidence of major depressive disorder can range from 15% to 40%. Depressive disorders can be on a spectrum and can include major depressive disorders, persistent depressive disorders, dysthymia, adjustment disorder, and demoralization syndrome. Diagnostic guidelines such as ICD-10 or DSM-V can be used to make a diagnosis. However, the clinician should be aware that there is overlap in the biological symptoms of depression and symptoms of cancer or adverse effects of the treatment. It is crucial and important to delineate the symptoms and make a correct diagnosis of depression. There are various approaches described below: Inclusive approach – To include all the symptoms of depression, even if some may be attributable to cancer Substitute approach – Somatic symptoms replaced by cognitive and affective symptoms (Endicott’s criteria)[3] Alternative approach – To add some new affective symptoms to the original criteria (Akechi’s criteria)[4] Exclusive approach – Somatic symptoms are excluded in entirety, and only affective symptoms are considered to make a diagnosis (Cavanaugh’s criteria).[5] For more details on the various approaches, readers are encouraged to read the references mentioned. Depressive disorders when identified and treated improve the QoL and decision-making capacity. Assessment A detailed assessment must be done with regard to a good history on independent symptoms and current treatment, past history – psychiatric and medical, detail family history, and also substance use history. Scales that help understand the intensity and severity are: Brief symptoms inventory Hospital anxiety and depression scale. These are widely used to assess psychological distress. These are specifically designed to detect depressive symptoms in medically ill patients. Other scales are as given below: Center for Epidemiological Studies – Depression Beck depression inventory. They have acceptable sensitivity and specificity in cancer patients. Management Treatment of depression in cancer patients with depression should also involve their families. Holistic care encompassed the following components of providing adequate information, support in making appropriate decisions, informed consent for psychotherapy and other management when necessary.All of this should be done while being sensitive and respectful to the patients familial, religious, cultural and ethnic background as well. The liaison between the cancer care physicians and mental health team is important for a well-coordinated care and good outcome of treatment. A list of contributing factors for depression are given in Box 3. NICE guidelines have given a flowchart for step-wise care for depression in people with cancer [Figure 1]. The management of mild, moderate, and severe depression is discussed in the previous IPS Guidelines on Depression and should be referred to for the treatment of depression in cancer as well.Box 3: Contributors for depressionFigure 1: Stepped care model for delivery of care[6] (adapted with permission)Pharmacological management Psychopharmacological studies show evidence that antidepressants are more effective than placebo in both cancer patients with major depressive disorder or depressive symptoms and distress related to cancer.[789] However, considering poor health status and adverse effects, the utility of ADs should be restricted to those with moderate-to-severe depressive episode. Those with mild depression should be started on ADs if psychosocial intervention does not produce desired change in mood or activity. Guidelines for the use of antidepressants in cancer patients[1] Medications are initiated at low dose and titrated very gradually to achieve an optimum individualized response (initial low doses have shown to reduce initial side effects and are better tolerated, particularly in patients with fragile physical conditions) Patients need to be informed about the time taken for titration, time after which medication has effects (latency period), and most common/serious adverse effects and monitoring if required. This helps in reducing medication stoppage, especially if patients are receiving other medications Treat the patient for a minimum period of 4–6 months to avoid relapses or recurrence of depression postremission Regular monitoring of vitals and blood parameters and check on the concomitant use of medications for cancer (e.g., steroids, antiemetics, antibiotics, antiestrogen, and chemotherapy agents) The process of stopping ADs should be a slow process and the clinician should keep in mind to reduce 25-50% of the dose once in 2-4 weeks. This reduces the risk of possible withdrawal symptoms that can be distressing for a patient. Sometimes, withdrawal may be mistaken for relapse of depression or worsening of symptoms of cancer Psychoeducation and reassurance are extremely important in oncology settings. Most of the evidence comes from case studies or open trials, and as per current research and guidelines practiced, selective serotonin reuptake inhibitors (SSRIs) are the first line of treatment as they have a lesser side effect profile. SSRIs – The most commonly used medications including citalopram, escitalopram, and sertraline are useful to treat depression in patients with cancer and also are found to be beneficial for anxiety and hot flashes. Duloxetine, an antidepressant along with treating depression, also has benefits in chronic musculoskeletal pain, chemotherapy-induced peripheral neuropathy, and neuropathic pain Serotonin norepinephrine reuptake inhibitors (SNRIs) – Venlafaxine and desvenlafaxine are used to treat major depression, anxiety, and neuropathic pain Tricyclic antidepressants (TCAs) – For neuropathic pain, TCAs have to be used judiciously as they can have severe and intolerable side effects such as constipation, dry mouth, and sedation Noradrenergic and specific serotonergic antidepressants (NaSSAs) – Mirtazapine can be used to treat sleep disturbances and nausea; the metabolic adverse effects have to be kept in mind. Nonpharmacological management The type of therapeutic intervention must be given due to thought considering symptoms and factors that contribute to depression. Recently diagnosed patients with cancer with mild-to-moderate depression may benefit from psychoeducation, cognitive-behavioral and Patients have more advanced may benefit from psychotherapy that on with and other of for those with advanced illness and a intervention referred to as and Table a list of 3: of psychological The demoralization first described by in is considered as a to a the is a such as treatment for their It can with other psychiatric disorders such as depression, anxiety, and adjustment Table the to demoralization from other psychiatric for various psychiatric seen in DISORDERS Introduction those diagnosed with anxiety is commonly seen as a response to or of and In cancer anxiety to a mild is seen in with and anxiety is at of and other However, anxiety at a disorder is seen in of cancer this is than is seen in general can in effective decision-making can and can with cancer and depression are seen to in a of people diagnosed with cancer. when is with can be mild to severe in anxiety spectrum disorders, we can anxiety, anxiety, specific disorder, and The clinical symptoms and diagnosis made on the criteria as per the ICD-10 or The assessment scales used to assess are the as those that are used in depressive disorders. It is important to anxiety depression, the symptoms do not This can be on the of mild anxiety Management In mild anxiety disorders, the first line of management is psychosocial in with poor response to treatment, pharmacological management should be In moderate-to-severe pharmacological management is with psychosocial treatment for adequate treatment. management The guidelines to start and treat with SSRIs in anxiety are those in depression. and can be used to treat and can be used to treat anxiety They should be and at the possible should be aware of the of and in those with in the and in and of in the and patients. The should be given at a minimum and titrated on and adverse effect profile. SSRIs that are used in cancer patients are citalopram, escitalopram, and while and can be used to treat anxiety as they have interaction with other should and avoid and as they can the of and can in cancer patients. can be used for as required. Other are and at low is an with no has for of Mirtazapine is a good of when anxiety is with and as sedation and possible which are common adverse effects, are seen to be beneficial and such as are also used in clinical to treat symptoms of The drugs with use are not and have not been in patients with cancer. Nonpharmacological management A nonpharmacological approach to anxiety and related symptoms has shown to be The various intervention include psychoeducation, and on cognitive and and and to help the person the thought process of such as and can help reduce and in The interventions not be to people in advanced or of their illness to family physical and adverse treatment effects are the issues in those receiving and and is an of cognitive and various such as and to enable the process of psychological The of are being in with the as a and can be used in individual and settings. It is shown to have in QoL cognitive cognitive to help a person be and of their and The of help to achieve a of the focus on and to look at as in the mind and not as the of Introduction disorders, is most commonly with cancer. is with of on of and is or is seen in of people diagnosed with and the incidence is in those with It can be due to various and and can also be due to as in Those at risk of are given in Box The medications in are in Box and of are in Box factors for in Box clinical of in Box and of in Box Those at risk of Medications that can of factors of in of is by an of disturbances of and that the of the of There are of on clinical and type of is by and low to of distress. by and is more is with of and of distress are in those with delirium, and are in as to Assessment The assessment should involve history of symptoms of delirium, and treatment assess of and all of and use to assess There are various to assess delirium, assessment assessment These scales are and can be used in cancer care assessment and the severity of delirium, we should assess for the of as in Box Management and assessment of delirium, any must be and should be to any in the The of treating is to a person not and management a first look for the current and any with to or The management of is we the readers to IPS Guidelines on Management of and the treatment of is the standard used to at doses of can be given or with and monitoring for risk of should be used with in those sensitive to and those with is an acceptable – and – can be in and in The evidence for the use of is can be used in patients with and distress. and can be used as It should be used with in the and may and depression. They can also worsening of start at the or can be 2 the patient is The of in has been There is one good of with in There are case to evidence for use of with in as well. and have shown some in ill patients. However, due should be given to the of of symptoms or of inhibitors and have been in the seen in However, they have not shown evidence to be beneficial in There have not been any studies done specifically on cancer. Hence, use of is not in cancer patients with There have been various studies at in care specifically in the pharmacological such as and have been the evidence is and more clinical The of sedation in is However, in some sedation may be required. should make this in with the and there should be informed and as a gradually to dose of very to the of doses of can be is of or can be is gradually titrated desired is Nonpharmacological management The of nonpharmacological interventions is and is used as a intervention to the The key aspects of the contributing and and treating are Nonpharmacological and do not have effect on or Nonpharmacological interventions can help in a in Nonpharmacological including cognitive help reduce distress in they are not effective in they do not any or of intervention – cognitive interventions and which the can be to do The cognitive interventions to cognitive while the intervention to with and the of the psychological interventions in and their interventions in interventions in in patients of advanced of cancer can contribute to distress for family crucial that must be the intervention is of family and their and response the patient. are about are seen to be more and to make good Introduction guidelines as a of cognitive or related to cancer or cancer and when severe does not improve with is also to the and with is seen in of people with can be at any of illness treatment, or and can even for the and effect is and This reduces the to and to in and may with that are The of to the of and other and has a to Assessment The most important to understand in is that is a underdiagnosed and Hence, we the need for and of and at to understand on QoL and cancer can be used to the severity of other scales that can be used are for and The first and is to a detailed history and focus on the of and A comprehensive and assessment should be done at contributing and In the of a history should assess the and the assessment should also include for substance use and A detailed physical on of and any other physical The should include blood blood and to any and when A list of and contributing of is given in Table the and contributing factors for and assessment of any have to be and the should be to for any There has been in or other have been In there are no one should the severity of and of and for mild and nonpharmacological management is for moderate-to-severe and severe of a of pharmacological and nonpharmacological management is management We should be aware that there are not clinical or on the of pharmacological management of and researchers have to look at the utility of and in the treatment of Here, we a summary of the The of such as and has shown to have some placebo in clinical can be used in there is no other for It can be used in treatment, and in clinical has not shown any a has shown in those with severe not in those with mild-to-moderate of has also shown benefits in patients with advanced in has not been in antidepressant has been or shown to have in and are to improve in people with or advanced illness and receiving also in general and of A has shown in cancer not in cancer must due to the adverse effects and of use of and should use in ill patients with and also in those with and with is a which has been and has not shown in at of and have also been and need more evidence and benefits in treating is on the utility of and in Nonpharmacological management Psychoeducation to the patients about adequate information, and to can help understand the and reduce and anxiety A looked at nonpharmacological treatment for benefits with physical and for such as that to in physical are beneficial to their The interventions can be done at individual or DISORDERS Introduction is in of those diagnosed with is with pain, anxiety, and about cancer and treatment. is with of anxiety and can for at after when with distress a person to physical and mental health issues which can in a poor most of the studies in this are in is the case that sleep can be a of has with and is seen at severity in those than Assessment patients with cancer have to be for in sleep and if to a disorder The of in a of outcome be used to for sleep with sleep on for or more a the sleep affect to both is for A detailed history should include details on time of to and time of sleep time taken to after on or sleep of sleep at quality of sleep and sleep look for substance use and sleep 2 weeks. This will the detailed of Scales severity assessment sleep quality for for sleep can be management There are no specific guidelines or approaches for treating sleep disorders in cancer. Nonpharmacological management is the management for management is used as a treatment to help the patient they interventions or in those to The pharmacological management should be for and should not should be used with as they have a risk of The approach should be effective dose for possible Other drugs such as and have been However, evidence in cancer patients and on adverse effect or interactions are Nonpharmacological management The treatment for is nonpharmacological specifically for It cognitive and and and sleep that are of are as such as and in to aspects of and sleep are to the of for sexual and only and can be to produce benefits sleep a sleep and and to at sleep must be and with a good do not a in to adequate avoid do not 2 to have an in and interventions – from individual psychotherapy to cognitive-behavioral and – have been effective in reducing anxiety and DISORDERS Introduction health is an important when the It has an on various health and in the health is in those diagnosed with cancer or in various of cancer including and of cancer have sexual health is and by psychosocial mental past and cultural a range of sexual such as in intensity or of sexual sexual and The sexual disorder to and patients are their treating physicians to to and help with the sexual due to cancer or that sensitive such as and sexual health must be by the patients the and the interventions to improve sexual health and QoL are Assessment A detailed history of the aspects to and phase should be taken in The cognitive and of by the symptoms to the patient and the should be the of and of and in to sexual should be A assessment will help in interventions for the person or in distress. Management The management of sexual disorders in cancer should a approach to improve sexual health and sexual in cancer patients and The management should include a between and psychosocial approaches which are individualized to the The the even can be more effective than when initiated when the sexual disorder or The following are the interventions by and of as per Assessment – The health must the on sexual and issues if any – – individual or with the patient for to be sexual – In can be used in However, the evidence in this is It should be as per of the clinician symptoms in – the patient does not have can be the patient is to start or can be and are better in with effects should be considered medications of pain – To start with or if there is no effective can be For persistent pain, can be there is no selective can be for do not have a or past history of cancer. For those with current or past history of can be These can be with and in – line of pharmacological management is for not to a of or can be there is no with the one can For of – symptoms in – Medications that can be used are and Nonpharmacological management are a between and factors related to cancer and treatment. The important in a life is good between the They should also be encouraged to that sexual and may include a more than The first line of nonpharmacological interventions such as sexual and may help reduce sexual in cancer patients or In of both sexual and should be Table the and factors to be and considered in sleep also an important in various of sexual among cancer patients and their issues A sexual in people diagnosed with cancer along with their and identified a need for interventions to improve and sexual for patient and and factors for interventions such as focus on and model of and for are in those information, and specific to improve sexual have not been DISORDERS Introduction more commonly is seen in of the However, of patients diagnosed with between the diagnosis of cancer and of The various for are the of people with to their the may be as a or a and a detailed is Studies have that people with are most commonly diagnosed in advanced of symptoms of can to and chemotherapy and can be with symptoms of The or can have a on the quality of of and as is that a of people are to in The quality of care is poor in the and psychiatric patients. The in following more to side effects of and other treatment The are of adverse in people with The management of in people with cancer is as in general the should adequate to the cancer and the medications to reduce adverse Nonpharmacological management can help in to the in or as a part of is by as a major which is for both patients and their for with other interventions such as and also have shown to be with in a team can help the patient in the clinical need for treatment, and assess the to consent and make which can improve the and is that and the of or There are various to to people or in of cancer other in the and are given The readers are encouraged to to the for of for and process of is in Box Guidelines for care to keep the person and in psychological and and also QoL care is a of health has been in to various such as cancer pain, individual family and The components are and These components have an in care and The clinician should be sensitive to important care such as for in the clinical and related to and The should be made in with the they to keep the person on the or a should be and the family and can be to be to the The family and must be encouraged and to the person with good This the use of pain It is important to in the use of in a and which in their are to good this time of of the patient and the family must be and even when the of the and must not be and should be and made with the is an which is an between oncology and Psychiatric disorders are being diagnosed in those with cancer. The psychiatric commonly seen are depressive spectrum disorders, adjustment disorders, anxiety disorders, and sleep and sexual disorders. The assessment, and treatment – pharmacological and nonpharmacological when for their specific – are seen to be more The of and be It is important to and treat the psychiatric illness which in will in the of QoL for those with cancer. support and of There are no of

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