Transcript Psychiatric Illness In The Cancer Patient

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