Assessment and treatment of psychosocial distress across the continuum
Kirsh, Kenneth L
ABSTRACT
Cancer and its treatment can create a great deal of distress for patients and can lead to a wide range of psychological disorders. While half of patients are able to adjust to the crises inherent in life with the disease, 30% will develop adjustment disorder and 20% will develop other psychiatric problems that may not be recognized by the oncology team until an observable crisis event occurs. These disorders fall along a broad continuum and can hinder the rehabilitation of the cancer patient. Problems may arise from adjustment issues and boredom all the way through depression and anxiety to delirium and dementia in the advanced cancer patient. While inter-related, these problems all have slightly different etiologies and need to be detected through screening programs. These issues are discussed along with potential treatments to consider.
INTRODUCTION
The rehabilitation of the oncology patient is a complex process offering many challenges. One such challenge is the detection and treatment of the common psychological and psychiatric complications of cancer that can have deleterious consequences on rehabilitation efforts and overall well-being. Rehabilitation professionals need to be aware of the signs and symptoms of psychiatric problems in people with cancer, how to use treatments, and/or recognize indications for referral to mental health professionals. Additionally, rehabilitation efforts are often offered to patients with advanced disease. Advanced cancer is a risk factor for the development of virtually all of the common psychiatric complications. Therefore, rehabilitation medicine professionals must in particular recognize the issues common to advanced cancer.
THE IMPACT OF CANCER ON THE PATIENT
Cancer, in psychological terms, is a chronic, often catastrophic stressor. How a patient adapts to it is key to his or her ongoing quality of life. All patients, even those with a good prognosis, face the challenges posed by the so-called ‘5 Ds’ of living with the disease.1 Coping with cancer means coping with death and issues of confronting mortality; accepting higher levels than usual of dependence while attempting to maintain one’s autonomy; being disabled by the disease and treatment and flexibly trying to overcome limitations; coping with disfigurement and changes in appearance that affect self esteem and role function; and finally, living with the disruption caused in life plans. The goal of research and clinical endeavors in psycho-oncology, palliative care, and quality of life is to help explicate these issues for patients (and family members) with specific sites and stages of disease and test and evaluate management strategies for their earlier recognition and treatment. The management of psychiatric complications is a key aspect of rehabilitation aimed at improving quality of life.
Cancer disrupts the lives of patients and their families.2 While half of patients are able to adjust to the crises inherent in life with the disease, 30% will develop adjustment disorder and 20% will develop other psychiatric problems that may not be recognized by the oncology team until an observable crisis event occurs.3 When this happens, medical treatments and rehabilitation efforts may be deleteriously affected. On the other hand, earlier recognition and treatment of psychiatric problems can facilitate rehabilitation efforts. This process begins with the differentiation of normal reactions to cancer from psychiatric syndromes.
NORMAL ADJUSTMENT TO CANCER
Once the diagnosis of cancer is communicated, patients live with a range of difficult emotions and adjustments. Chronic stress becomes a part of every day life in dealing with feelings of loss, grief, fear, and anger. In addition to the chronic stress, patients face crisis points throughout the disease process. Patients experience high levels of anxiety that accompany the beginning of new treatment; waiting for test results; learning that treatments have failed or of recurrence of disease; and struggling with pain, fatigue, and other debilitating conditions. Other psychosocial concerns after cancer diagnosis, which may contribute to feelings of stress, typically include vocational problems, cognitive impairments, sexuality and sexual response issues, financial concerns, family and social problems, physical discomfort, and excessive worry.4-7 Patients must also deal with the anxiety about making end-of-life decisions (such as health care proxies and do not resuscitate orders) and other existential and interpersonal issues.8 In the cycle that corresponds to adjustment to these crises, characteristic emotional responses include feelings of disbelief, despair, or denial accompany the receipt of bad news, which generally lasts about a week. This may be followed by a period marked by sleep and appetite disturbance, anxiety, irritability, ruminative thoughts, and fears about the future. Patients may have trouble concentrating and their ability to carry out usual daily activities may be impaired. Approximately half of patients will successfully adapt within a few days to a few weeks with support from family and friends.1
Adaptation is characterized by the patient beginning to acclimate to and accept the threatening information, preparing for treatment, adjusting lifestyle to meet medical needs, and attempting to maintain a positive outlook for the future.9 Physicians and other medical staff can help this adjustment process by providing clear medical information. Patients benefit from having a treatment outline, and knowing what to expect through the treatment process both physiologically and psychologically. Medical staff can be supportive by offering a sense of hope. Even in the most critical situations, patients generally respond to reassurance that they will not die alone or in pain. This process can be highly distressing, yet approximately half of cancer patients will navigate the emotional ups and downs without ever qualifying for a psychiatric diagnosis.10 At times, prescribing a hypnotic, or low dose sedating antidepressant to promote normal sleep and/or a daytime sedative (benzodiazepine) to reduce anxiety can help through the crisis period and facilitate adaptation.1
Some patients continue to have high levels of anxiety and depression for weeks or even months. This is beyond the normal time course for adjustment. While this persistent distress is reactive in nature, it is neither normal nor adaptive. Emotional distress over long periods alters physical and psychological functioning. Ability to work, family and social relations, and capacity to participate and comply with their medical care can all be negatively affected by comorbid psychiatric symptoms.
PSYCHOLOGICAL DISTRESS
Cancer patients have a high rate of psychiatric comorbidity and approximately half of all patients diagnosed with cancer exhibit emotional difficulties.10 Generally, the psychological complications take the form of adjustment problems, depressed mood, anxiety, impoverished life satisfaction, or loss of selfesteem.6,7,12 Cancer patients most at risk for depression and other psychiatric illness are those with advanced disease, a prior psychiatric history, poorly controlled pain, and other life stressors or losses.13 However, the making of psychiatric diagnoses and the rapid identification of patients in need of help are difficult for many reasons. One problem is that psychiatric symptomatology may be mimicked by treatment side effects or symptoms of the disease in people with cancer. Time factors and patient reluctance to discuss psychosocial problems can also act as barriers to the recognition of psychosocial problems.14
BOREDOM
Boredom is a sign of not being actively engaged in one’s life. Little joy is present, activity is decreased, and, if prolonged, can lead to depression and/or aggression.15 The problem of boredom in people with cancer has received little research attention and yet clinical experience suggests that it has the potential to profoundly affect quality of life in those patients. Boredom can stem from many sources in the life of a cancer patient. While depression and lack of motivation are often recognized, other subgroups of patients may want to do things but simply not have the energy; others may have still other needs and, because they already feel they are a burden on friends and/or family, be reluctant to ask for additional assistance in doing activities simply for enjoyment. Often the enormous amount of time involved in the treatment process leaves little time or energy for the more rewarding activities of life. The problem of boredom as a health care issue has been subsumed under research on other complaints such as depression, apathy, or fatigue. Although there are many common elements among the related concepts, boredom appears to have enough unique qualities to warrant a separate consideration.
ADJUSTMENT DISORDER
Adjustment disorder is a psychiatric diagnosis characterized by a variety of clinically significant behavioral or emotional symptoms, occurring as a result of a triggering event or stressor.16 Growing out of the concept of reactive depression, the disorder may be associated with the following subtypes: depressed mood, anxiety, or disturbance of conduct.17,18 The onset of adjustment disorder must occur within 3 months of the triggering event and must not endure past 6 months of the termination of the stressor or its consequences. However, the disorder can be deemed chronic, thus lasting more than 6 months, when there is a chronic stressor or when the consequences of the stressor have long-term impact (such as is often the case for people with cancer). Adjustment disorder can only be diagnosed if the disturbance is unique and does not meet the criteria for other disorders, such as major depression or generalized anxiety disorder, and if the symptoms are not a result of bereavement.16
Adjustment disorder is the most prevalent psychiatric problem associated with cancer. In fact, it is evident in 25% to 30% of all patients with cancer.10,19 The identification and diagnosis of adjustment disorder is not straightforward. One of the problems with the adjustment disorder diagnosis is that it lacks precise features. While other disorders have symptoms that are clearly described, adjustment disorder remains vague.17 Adjustment disorder is not a symptom-based diagnosis but a function-based one. Further, there are no set criteria for quantifying the stressors that lead to adjustment disorder in a given individual.20 Additionally, it is often difficult to define what constitutes maladaptive behavior in response to catastrophic levels of stress. The severity of symptoms and/or decrement in social function can vary widely within a given individual over time.21 However, although the diagnosis of adjustment disorder lacks specificity, its treatment is no less challenging or less important for patients with cancer than any other psychiatric problems.14 Identification of adjustment disorder is important, as patients with adjustment disorder generally benefit from some form of counseling intervention.
Rehabilitation professionals attempting to identify patients who could benefit from counseling should focus on a lack of flexibility on the part of the patient.22,23 Those who develop adjustment disorder may be more likely to be rigid in their thinking and determined to address their cancer-related problems in the same manner as they did prior stressors. Should the old coping and problem-solving strategies fail, the person may begin to exhibit the reactions of depressed mood and anxiety associated with adjustment disorder. In contrast, those who successfully adapt typically have a flexible style.24
DEPRESSION
The diagnosis of depression in physically healthy patients depends heavily on the presence of somatic symptoms such as decreased appetite, loss of energy, insomnia, loss of sexual drive, and psychomotor retardation. These neurovegetative symptoms of depression are very compelling when present in the absence of physical illness. These symptoms taken alone, however, are somewhat less reliable as diagnostic criteria for depression in patients with cancer, since they are highly likely to be caused by cancer or its treatment. Loss of appetite due to chemotherapy, fatigue due to cancer, and lack of sleep due to unrelieved pain are examples of the problems in differentiating somatic symptoms due to depression or other medical causes. Physical symptoms must be carefully evaluated to clarify their etiology and target them for intervention. However, due to the correlation between higher levels of symptom distress and the other more reliable cognitive or ideational symptoms they should not be discounted. Assessing these symptoms can be a way to open a dialogue with the patient who might otherwise resist discussions of emotional issues (ie, those who are not psychologically minded). Moreover, antidepressants can be chosen so as to target the physical symptoms that are most distressing to the patient.” Certain drugs used in the treatment of cancer, such as prednisone, decadron, procarbazine, vinicristine, and vinblastine cause depressive symptoms that may be confused with adjustment disorder or mood disorder through their side effects.18 Such confounding of the diagnosis can lead to improper treatment offered to patients or cause the disorder to be overlooked as merely a drug side effect.
Persistently depressed mood and sadness can be an appropriate response for a patient with a life-threatening disease so the diagnosis of depression in cancer patients, especially those who have advanced disease, relies more on the other psychologic or cognitive symptoms. Anhedonia is a useful, if not the most reliable, depressive symptom to monitor.'” Cancer patients who are not depressed, while periodically sad, maintain the capacity for experiencing pleasure. Such patients react positively to opportunities to engage in the activities that they enjoy, even though the range of activities available to them may be diminished. There is nothing inherent to the disease or treatment process that robs one of the capacity to feel pleasure. Indeed, some patients with far advanced disease experience heightened pleasure in, for example, intimacies with family or friends knowing that the experiences are among the last they might have; the knowledge that death is near can increase the poignancy and emotion in such contacts.26 Feelings of hopelessness, worthlessness, excessive guilt, loss of self-esteem, and wishes to die are also among the most diagnostically reliable symptoms of depression in cancer patients.
The interpretation of even these more reliable symptoms can be difficult. For example, feelings of hopelessness in dying patients who have no hope for recovery can be normal. While many cancer patients never have a hope of a cure, they are able to maintain hope that life can be extended, symptoms can be controlled, and/or quality of life can be maintained. Hopelessness that is pervasive, and accompanied by a sense of despair or despondency is more likely to present a symptom of a depressive disorder. Similarly, patients often state that they feel they are burdening their families unfairly, causing them great pain and inconvenience. These beliefs can be altered by counseling the patient and helping them to reframe the care they need as something their family needs to provide as part of the mourning process.26 The patient can come to see that allowing him or herself to be cared for is important for their family’s sake. Thus, such beliefs are less likely to represent symptoms of depression than if the patient suffers with guilty recrimination, feels that their life has never had any worth, or that they are being punished for evil things they have done. Suicidal ideation, even rather mild and passive forms, is very likely associated with significant degrees of depression in patients with advanced cancer.
ANXIETY
Oncology patients may present with a complex mixture of physical and psychological symptoms in the context of their frightening reality. Thus the recognition of anxiety symptoms requiring treatment can be challenging. Patients with anxiety complain of tension or restlessness, or they exhibit jitteriness, autonomic hyperactivity, vigilance, insomnia, distractibility, shortness of breath, numbness, apprehension, worry, or rumination. Often the physical or somatic manifestations of anxiety overshadow the psychological or cognitive ones.27 These symptoms are a cue to further inquiry about the patient’s psychological state, which is commonly one of fear, worry, or apprehension in cancer patients. In deciding whether to treat anxiety, the patient’s subjective level of distress is the primary impetus for the initiation of treatment. Other considerations include problematic patient behavior such as noncompliance, family, and staff reactions to the patient’s distress, and the balancing of the risks and benefits of treatment.28
Anxiety, like fever, is a symptom in this population that can have many etiologies. Anxiety may be encountered as a component of an adjustment disorder, panic disorder, generalized anxiety disorder, phobia, or agitated depression. Additionally, in the cancer patient with advanced disease, symptoms of anxiety are most likely to arise from some medical complication of the illness or treatment such as organic anxiety disorder, delirium, or other organic mental disorders.27-29 Hypoxia, sepsis, poorly controlled pain, and adverse drug reactions such as akathisia or withdrawal states are specific entities that often present as anxiety. Benzodiazepine withdrawal for example, can present first as agitation or anxiety, though the diagnosis is often missed in cancer patients with advanced disease, and especially the elderly, where physiologic dependence on these medications is often unrecognized.30
Despite the fact that anxiety in cancer patients commonly results from medical complications, it is equally often psychological factors related to existential issues that cause anxiety, particularly in patients who are alert and not confused.27 Patients frequently fear isolation, estrangement from others, and may have a general sense of feeling like an outcast. Also, financial burdens and family role changes are common stressors.
DELIRIUM AND DEMENTIA
Delirium has been characterized as an etiologically nonspecific, global, cerebral dysfunction, characterized by concurrent disturbances of level of consciousness, attention, thinking, perception, memory, psychomotor behavior, emotion, and the sleep– wake cycle. Disorientation, fluctuation, or waxing and waning of the above symptoms, as well as acute or abrupt onset of such disturbances are other critical features of delirium. Delirium is also conceptualized as a reversible process, as compared to dementia. At times it is difficult to differentiate delirium from dementia since they frequently share such common clinical features as impaired memory, thinking, judgment, and disorientation. Dementia appears in relatively alert individuals with little or no clouding of consciousness. The temporal onset of symptoms in dementia is more insidious or chronically progressive, and the patient’s sleep-wake cycle is generally not impaired. Most prominent in dementia are difficulties in short- and long-term memory, impaired judgment, and abstract thinking as well as disturbed higher cortical functions (ie, aphasia, apraxia, etc.). Occasionally one will encounter delirium superimposed on an underlying dementia such as in the case of an elderly patient, an AIDS patient, or a patient with a paraneoplastic syndrome31
Delirium is most common in patients with far advanced cancer. Between 15% and 20% of hospitalized cancer patients have organic mental disorders.32-33 Massie and colleagues found delirium in more than 75% of terminally ill cancer patients they studied.34 Delirium can be due either to the direct effects of cancer on the central nervous system (CNS), or to indirect CNS effects of the disease or treatments (medications, electrolyte imbalance, failure of a vital organ or system, infection, vascular complications, and pre-existing cognitive impairment or dementia). Early symptoms of delirium can be misdiagnosed as anxiety, anger, depression, psychosis, or unreasonable or uncooperative attitudes toward rehabilitative efforts or other treatments. In any patient showing acute onset of agitation, impaired cognitive function, altered attention span, or a fluctuating level of consciousness, a diagnosis of delirium should be considered.35 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. For example, given the large numbers of drugs cancer patients require, and the fragile state of their physiologic functioning, even routinely ordered hypnotics are enough to create an organic mental syndrome. Opioid analgesics such as levorphanol, morphine sulfate, and meperidine are common causes of confusional states, particularly in the elderly and patients with advanced disease.36 Chemotherapeutic agents known to cause delirium include methotrexate, fluorouracil, vinicristine, vinblastine, bleomycin, BCNU, cis-platinum, asparaginase, procarbazine biological response modifiers, and the glucocorticosteroids.37-42 Except for steroids and biological response modifiers, most patients receiving these agents will not develop prominent CNS effects. The spectrum of mental disturbances related to steroids includes minor mood lability, affective disorders (mania or depression), cognitive impairment (reversible dementia), and delirium (steroid psychosis). The incidence of these disorders range from 3% to 57% in noncancer populations, and they occur most commonly on higher doses. Symptoms usually develop within the first 2 weeks of treatment, but in fact can occur at any time, on any dose, even during the tapering phase.37 Prior psychiatric illness, or prior disturbance on steroids are poor to fair predictors of susceptibility to, or the nature of, mental disturbances during subsequent steroid treatments. These disorders are often rapidly reversible upon dose reduction or discontinuation.
SCREENING FOR PSYCHIATRIC PROBLEMS
An effective screening program can be an invaluable part of efforts aimed at identifying cancer patients at risk for psychiatric problems.43 Large batteries of tests and assessment instruments are simply not practical for many oncology settings, due to cost and time pressures. With the high prevalence of psychiatric problems and the multitude of symptoms with which the clinician is often confronted, the use of brief self-report screens is essential.10,14 The measures must be deemed to have acceptable levels of sensitivity and specificity for the setting in which they are employed. Specificity refers to the ability of the screen to correctly identify those patients who are not under distress, while sensitivity refers to the ability of the test to accurately identify those patients who are under a high degree of distress.43
One of the main benefits to the use of self-report screens is their anonymity. Patients may inhibit or conceal their personal distress to staff so as not to distract from the treatment of the disease or to be perceived as weak. Although a patient knows that his or her answers will be evaluated, they may answer questions on a screening questionnaire in a more forthright and honest way than they might if questioned face-to-face.43 The end result of screening can lead to the early identification of patients in distress, which can be a benefit to the comprehensive medical care, satisfaction, and quality of life of the patient.45
TREATMENT OVERVIEW
Depression and organic mental disorders (eg, delirium, dementia) are the most prevalent psychiatric disorders among patients with advanced disease. Patients presenting with organic mental syndromes are often very fatigued, mildly confused, and/or have memory deficiencies that can severely impede the implementation of successful rehabilitation efforts. Stimulants and neuroleptics, either alone or in combination, are useful in decreasing levels of fatigue and improving mental status. Patients who are able to actively comprehend and remember the nature and goals of the rehabilitation process will ultimately enjoy much improved chances of maximizing their function and quality of life.
In addition to pharmacological approaches, there are a variety of psychotherapeutic interventions that are very beneficial in facilitating treatment compliance with rehabilitative efforts. In addition to evaluation and treatment of any psychiatric syndromes, efforts should be made to evaluate the patient’s motivation for rehabilitation. Motivation is a significant component of a successful physical rehabilitation plan. Some patients may wish to go it alone, which can be a recipe for failure and lowered self-esteem and motivation, while individuals with advanced malignancies may feel that rehabilitation is futile given their poor prognosis. Behavioral interventions that foster an increased level of motivation in the patients are very beneficial in maximizing compliance with the rehabilitation process and minimizing frustration. In addition, the involvement of family in the planning of the rehabilitation program is also very helpful. Interventions such as appropriate goal setting, journal keeping, self-monitoring, and reinforcement principles are very instrumental, facilitating a level of motivation conducive to successful rehabilitation.
Psycho-oncologists provide a unique dimension to the rehabilitation process not afforded by other members of the rehabilitation team. The implementation of psychotherapeutic, such as cognitive-behavioral techniques, and psychopharmacological interventions that directly address deficits commonly present in the patient requiring rehabilitation (eg, pain, insomnia, anxiety) are of significant benefit. The uses of relaxation techniques, in combination with pharmacological treatment, are beneficial in minimizing the symptoms of panic commonly expressed in patients with pulmonary complications. Anxiety and psychological distress related to difficulties breathing (eg, shortness of breath) are frequently encountered and may discourage the patient from complying with rehabilitation efforts. Other direct cognitive behavioral interventions that focus on the reduction of pain, insomnia, and eating difficulties can be equally beneficial.
Psycho-oncologists have a variety of pharmacological tools available that address the symptomology commonly found within this patient population. Clinicians should consider the implementation of a psychotropic drug intervention that is directly aimed at decreasing the patient’s level of fatigue and pain and facilitates improvement in sleeping. Because all of these symptoms negatively impact the patient’s rehabilitation program and overall quality of life, psychotropic drugs (eg, tricyclic antidepressants) that directly address deficits and improve levels of energy and motivation will permit the patient to benefit from rehabilitation.
STAFF EDUCATION
Because of the relatively recent development of the field of psycho-oncology, there are relatively few large psycho-oncology services outside of academic centers. Therefore, a key role of psycho-oncologists is in educating rehabilitation medicine staff about the psychological aspects of cancer and the interventions that they might adopt from psycho-oncologists that will maximize rehabilitative efforts. The staff will be able to use these techniques early in their training and subsequently carry this knowledge to future positions at other institutions. The use of case focused conferences and multidisciplinary rounds for staff are very beneficial in facilitating discussion of the psychological aspects of cancer rehabilitation. Similarly, work-related support groups allow for staff to share their perspectives on patient management and should help to increase morale and decrease levels of frustration and burnout.
TREATMENT OF ADJUSTMENT DISORDERS
The ultimate utility of adjustment disorder as a diagnostic category for oncology is to identify those patients who may be in need of intervention and who do not meet full criteria for DSM– IV diagnoses such as major depression or generalized anxiety disorder. Although future research may ultimately show that adjustment disorder is a form of subclinical depression, the fact remains that persons identified as having adjustment disorder are often associated with being at risk for increased morbidity and even mortality (ie, suicide).46 It is important to note, however, that persons with adjustment disorder have been shown to have positive outcomes when they are treated with brief psychotherapy, the usual form of psychotherapy employed by psycho-oncologists.47 This allows for the possibility of early treatment using nurses and other staff before a problem worsens to the point of requiring more intensive care and medications.48,49 Psychotherapy for adjustment disorder addresses the stressors directly by teaching enhanced coping skills and is focused on immediacy. Establishing social support networks and psychoeducation are also employed.50,51 Informal support groups and more formal group therapy have been shown to be highly effective for improving quality of life and decreasing depression and anxiety symptoms in cancer patients.43,52 The rapid identification of adjustment disorder can prompt early psychological intervention that can help to promote the patient’s quality of life, or at the very least, may prevent the further erosion of the patient’s ability to function.17
TREATMENT OF DEPRESSIVE DISORDERS
Depression in patients with cancer is best managed using a combination of supportive psychotherapy, cognitive-behavioral techniques, and antidepressant medications. Psychosocial interventions are used to help individuals, families, and groups. The general objective of this therapy is to improve coping skills through educational, behavioral, or psychodynamic approaches. Cognitive-behavioral approaches explore patients’ beliefs about the cancer diagnosis and its treatment in order to elicit irrational or unhelpful thoughts that lead to feelings of helplessness and hopelessness. This approach then will lead to the correction of these maladaptive thoughts along with providing new coping skills (ie, relaxation). Group and individual treatment have been demonstrated to be effective in reducing depressive symptoms and distress and improving quality of life.53,54
PHARMACOLOGIC TREATMENT OF DEPRESSIVE DISORDERS
Psychopharmacologic interventions are the mainstay of management in the treatment of patients with moderate to severe levels of depression. Clinical experience has demonstrated that antidepressants are safe and effective in the treatment of depression and depressive symptoms. Antidepressant medications that can be useful for the treatment of depression in cancer patients are the tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), heterocyclic antidepressants, and psychostimulants. Cancer patients with early stage disease are not much different from the average individual who needs an antidepressant. Clinical experience suggests that the patient with early cancer can be as safely and effectively treated with SSRIs and TCAs with similar dose titrations as anyone in the physically healthy population. More advanced disease along with increased levels of physical distress make the clinical decisions regarding antidepressants more complex and challenging.
Attention to potentially upsetting or harmful side effects of the different classes of antidepressants is warranted. Cardiac arrhythmias, orthostatic hypotension, and anticholinergic effects are among the most serious side effects of the TCAs. While these side effects are problematic, many times other side effects can be used to the patient’s advantage. When considering which antidepressant to use, the clinician must think in terms of side effects mobilization versus side effect minimization. Sedation may be useful to the agitated patient who is anxious and cannot sleep; whereas, the side effect of activation may be useful to the hypersomnolent, withdrawn patient with lethargy. Some antidepressants stimulate appetite – a useful side effect when appetite is decreased.
NONPHARMACOLOGIC TREATMENT OF DEPRESSIVE DISORDERS
Cancer patients with depression are often reacting to the burden of the illness and the effect it has on their lives. Clinicians working in oncology rely primarily on short-term supportive psychotherapy based on a crisis intervention model to help patients with depressive symptomatology. Cognitive-behavioral techniques are often integrated into treatment and are very useful and effective. These therapies explore methods of enhancing coping skills and problem-solving skills, facilitating communication between the patient and others, revitalizing social support networks, and reshaping negative or self-defeating thoughts.
The crisis intervention model is the basis for much oncology– related psychotherapy. Crisis intervention is a process for actively influencing psychosocial functioning during a period of disequilibrium. It is directed at alleviating the immediate impact of disruptive stressful events. The aim is to reduce emotional distress while working toward strengthening the patient’s psychological and social resources. Generally, crisis therapy is time limited and asserts clear-cut goals.55 Supportive/crisis intervention psychotherapy involves clarifying information and answering questions about the illness and its treatment, correcting misunderstanding, and giving reassurance about the situation. Describing common reactions to illness may help the patient and their family to normalize their experience. Patients’ usual adaptive strategies should be explored and their strengths supported as needed in adjustment. The patients should be encouraged to discuss how they feel about their lifestyle modifications, their family role changes, and their fears of dependency and abandonment. Themes of loss and anticipatory grief should also be explored. Patients often experience loss of good health, body integrity, and selfesteem, along with losses secondary to cancer (eg, financial, social, and occupational). Therapy should seek to improve a sense of control and morale. When the focus of treatment changes from cure to palliation, it will be extremely important for the patient to know that while curative treatment has ended they will not be abandoned and that their comfort, pain control, and dignity will receive continued attention.
Cognitive-behavioral interventions help patients allay exaggerated fears by encouraging patients to consider different possible outcomes for their situation. Helping the patient focus on what aspects of the disease and its treatment that the patients have control over and encouraging behavior modification that will keep them involved and positive could provide a better quality of life for these patients. Relaxation techniques and imagery may enhance any of these therapeutic interventions. Simple focused breathing exercises, meditation, and progressive muscle relaxation can be used to lessen the episodic anxiety that many cancer patients experience. Pleasant imagery, such as visualizing a gentle stream flowing through a beautiful landscape, can also ease the tension some patients feel.
Support groups are important adjunctive intervention modalities for cancer patients and family members who are distressed. Hospitals and community organizations will often sponsor groups that are professionally run and/or self-help. The professionally run groups will usually use educational, supportive, or cognitive– behavioral methods while the lay groups generally focus on education, practical advice, modeling, and serving as a source of mutual support and advocacy.
TREATMENT OF ANXIETY DISORDERS
The treatment of anxiety in cancer patients also involves the combination of psychotherapy and a range of anxiolytic medications. The pharmacotherapy of anxiety in patients with more advanced illness involves the judicious use of the following classes of medications: benzodiazepines, neuroleptics, antihistamines, antidepressants, and opioid analgesics.27,28
Benzodiazepines
Benzodiazepines are the mainstay of the pharmacologic treatment of anxiety in cancer patients. The shorter acting benzodiazepines, such as lorazepam, alprazolam, and oxazepam, are safest in this population. The selection of these drugs avoids toxic accumulation due to impaired metabolism in debilitated individuals.56 Lorazepam and oxazepam are metabolized by conjugation in the liver and are therefore safest in patients with hepatic disease. This is in contrast to alprazolam and other benzodiazepines that are metabolized through oxidative pathways in the liver that are more vulnerable to interference with hepatic damage. The disadvantage of using short-acting benzodiazepines is that patients often experience breakthrough anxiety or end of dose failure. Such patients can benefit from switching to longer acting benzodiazepines such as diazepam or clonazepam. Clonazepam, a longer acting benzodiazepine, has been found to be extremely useful, in our setting, for the treatment of symptoms of anxiety. Patients who experience end of dose failure with recurrence of anxiety on shorter acting drugs also find clonazepam helpful. It is not uncommon for us to switch patients from alprazolam to clonazepam when attempting to taper off alprazolam. Clonazepam is also useful in patients with organic mood disorders who have symptoms of mania, and as an adjuvant analgesic in patients with neuropathic pain.57,58 Fears of causing respiratory depression should not prevent the clinician from using adequate dosages of benzodiazepines to control anxiety. The likelihood of respiratory depression is minimized when one uses shorter acting drugs, increases the dosages in small increments, and ultimately switches to longer acting drugs.
Non-Benzodiazepine Anxiolytics
Typical and atypical neuroleptics, such as thioridazine, haloperidol, and olanzapine are useful in the treatment of anxiety when benzodiazepines are not sufficient for symptom control.26 They are also indicated when an organic etiology is suspected or when psychotic symptoms such as delusions or hallucinations accompany the anxiety. The atypical neuroleptics, such as olanzapine, can control anxiety related to confusional states, delusions, and nausea.59,60 Neuroleptics are perhaps the safest class of anxiolytics in patients where there is legitimate concern regarding respiratory depression or compromise. Methotrimeprazine is a phenothiazine with unique analgesic and anxiolytic properties that is often used for the treatment of pain and anxiety in the patient with advanced cancer.61-62 Its side effects include sedation, anticholinergic symptoms and hypotension. Intravenous administration by slow infusion is preferable to avoid problems with hypotension. Chlorpromazine has similar side effects that limit its application in this setting. However, it can be useful in patients where sedation is desirable. With this class of drugs in general, one must be aware of extrapyramidal side effects (particularly when patients are taking additional neuroleptics for antiemetic purposes) and the remote possibility of neuroleptic malignant syndrome. Tardive dyskinesia is rarely a concern given the generally short-term usage and low dosages of these medications in this population.63 The atypical neuroleptics offer the advantage of not causing extrapyramidal symptoms in the doses generally used (ie, olanzapine 2.5 – 5.0 mgs, QD – BID).
Hydroxyzine is an antihistamine with mild anxiolytic, sedative, and analgesic properties. It is particularly useful when treating anxious, cancer patients with pain. One hundred milligrams of hydroxyzine given parenterally has analgesic potency equivalent to 8 mg of morphine and potentiates the analgesic effects of morphine.64 As an anxiolytic, 25 mg to 50 mg of hydroxyzine q 4– 6 hours PO, IV, or SC is effective.
Tricyclic, SSRIs, and heterocyclic antidepressants are the most effective treatment for anxiety accompanying depression and are helpful in treating panic disorder.65,66
Buspirone is a nonbenzodiazepine anxiolytic that is useful along with psychotherapy in patients with chronic anxiety or anxiety related to adjustment disorders. The onset of anxiolytic action is delayed in comparison to the benzodiazepines, taking 5 to 10 days for relief of anxiety to begin. Since buspirone is not a benzodiazepine, it will not block benzodiazepine withdrawal, and so one must be cautious when switching from a benzodiazepine to buspirone. The effective dose of buspirone is 10 mg po tid.67 Because of its delayed onset of action and indication for use in chronic anxiety states, buspirone may have limited usefulness to the clinician treating anxiety in the rehabilitation setting with cancer patients.
Nonpharmacologic Treatment of Anxiety Disorders
Nonpharmacologic interventions for anxiety and distress include supportive psychotherapy and behavioral interventions that are used alone or in combination. Brief supportive psychotherapy is often useful in dealing with both crisis-related issues as well as existential issues.68 Psychotherapeutic interventions often include both the patient and family, particularly as the patient with cancer becomes increasingly debilitated and less able to interact. The goals of psychotherapy for the anxious patient are to establish a bond that decreases the sense of isolation; to help the patient face cancer with a sense of integrity and self worth; to correct misconceptions about the past and present; to integrate the present illness into a continuum of life experiences; and to explore issues of separation, loss, and the unknown that lies ahead. As in the treatment of depression, the therapist should emphasize past strengths and support previously successful ways of coping. This helps the patient mobilize inner resources, modify plans for the future, and perhaps even accept the inevitability of death.
Relaxation, guided imagery, and hypnosis may help reduce anxiety and thereby increase the patient’s sense of control. Most patients with cancer, even those with advanced disease, are appropriate candidates for useful application of behavioral techniques despite physical debilitation. In assessing the utility of such interventions for a given patient, the clinician should take into account the patient’s mental clarity. Confusional states interfere dramatically with a patient’s ability to focus attention and thus limit the usefulness of these techniques.by Occasionally these techniques can be modified so as to include even mildly cognitive impaired patients. This often involves the therapist taking a more active role by orienting the patient, creating a safe and secure environment, and evoking a conditioned response to the therapist’s voice or presence. A typical behavioral intervention for anxiety includes a relaxation exercise combined with some distraction or imagery technique. The patient is first taught to relax with passive breathing accompanied by either passive or active muscle relaxation. Once in such a relaxed state, the patient is taught a pleasant, distracting imagery exercise. In a randomized study comparing a relaxation technique with alprazolam in the treatment of anxiety and distress in cancer patients, both treatments were demonstrated to be quite effective for mild to moderate degrees of anxiety or distress. The drug intervention (alprazolam) was more effective for greater levels of distress or anxiety and had more rapid onset of beneficial effect.70 Often, such interventions are used in combination, ie, using relaxation techniques concurrently with anxiolytic medications in highly anxious cancer patients.
MANAGEMENT OF DELIRIUM
A standard approach for managing delirium in the cancer patient includes a search for underlying causes, correction of those factors, and management of symptoms. In addition to seeking out and correcting the underlying cause for delirium, symptomatic and supportive therapies are important.35 Fluid and electrolyte balance, nutrition and vitamins may be helpful. Measures to help reduce anxiety and disorientation (ie, structure and familiarity) may include a quiet, well-lit room with familiar objects, a visible clock or calendar, and the presence of family. Judicious use of physical restraints, along with one-to-one nursing observation may also be necessary and useful. Often, these supportive techniques alone are not effective, and symptomatic treatment with neuroleptic or sedative medications are necessary. Sedation may be necessary to relieve severe agitation or insomnia.35
Haloperidol, a neuroleptic agent that is a potent dopamine blocker, is the drug of choice in the treatment of delirium in the medically ill.35,71,72 Haloperidol in low doses, I to 3 mg, is usually effective in targeting agitation, paranoia, and fear. Typically 0.5 mg to 1.0 mg haloperidol (PO, IV, IM, SC) is administered, with repeat doses every 45 to 60 minutes titrated against symptoms.34,69 A common strategy in the management of symptoms related to delirium, is to add parenteral lorazepam to a regimen of haloperidol. Lorazepam 0.5 mg to 1.0 mg q 1-2h PO or IV, along with haloperidol may be more effective in rapidly sedating the agitated delirious patient. The atypical antipsychotics may have an as yet, under-appreciated role in the management of cognitive disorders in cancer patients. Passik and Cooper reported a case of a patient with delirium successfully treated with olanzapine.60
CONCLUSION
Patients undergoing rehabilitation efforts during or after cancer treatment often have comorbid psychiatric problems that can hinder these programs. Identification and management can often be accomplished by the rehabilitation team, sometimes in consultation with mental health professionals. Working together, the team can enhance quality of life for the patient and family.
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Kenneth L. Kirsh, PhD
Steven D. Passik, PhD
Symptom Management and Palliative Care Program, Markey Cancer Center, University of Kentucky, Lexington, KY
Copyright Rehabilitation in Oncology 2002
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