OncoLog

 

From OncoLog, August 2012, Vol. 57, No. 8

Addressing Psychological Concerns for Cancer Patients 

By Dawn Chalaire

“If we can bring the joy back in somebody’s life, then we have accomplished our goal.”
– Dr. Anis Rashid

Despite advances in cancer treatment over the past several years, for many people, a diagnosis of cancer can still feel like a death sentence. The added stress leads to psychological problems for many patients.

“Many cancer patients are overwhelmed,” said Anis Rashid, M.D., an associate professor in the Department of Psychiatry at The University of Texas MD Anderson Cancer Center. “I have seen patients so distressed that they feel they are falling apart and have no control. This leads to increased anxiety.”

In a setting where the goal of everyone involved—oncologists, radiologists, nurses, patients, and family—is eradication of the disease, a patient’s psychological issues can be downplayed or overlooked. But according to Dr. Rashid, anxiety and depression are common among cancer patients and should be viewed in the same way as any physical symptom that causes a patient distress.

“Treating these symptoms is important for the overall well-being of the patient,” Dr. Rashid said. “If patients are hurting, we need to control their pain. If they’re not sleeping, we need to make them sleep better, and if they have a lot of anxiety, we need to treat it.”

Anxiety in cancer patients

A cancer diagnosis triggers anxiety in up to 40% of patients, Dr. Rashid said. The symptoms of anxiety may include feelings of uneasiness, irritability, difficulty sleeping or staying asleep, increased pain perception, and poor memory and concentration. In cancer patients, anxiety is usually worst during the first 3 months after diagnosis. Initially, patients do not know the stage of their cancer or the type of treatment they will receive, and this uncertainty can contribute to their anxiety.

Cancer patients can also be overwhelmed by the volume of information they receive about their disease and its treatment; this information can come from many different sources and is sometimes contradictory. Such information overload, and specifically contradictory information, can cause anxiety. This anxiety makes it even more difficult for patients to process all the information and make treatment decisions.

A diagnosis of cancer can also trigger a period of great upheaval in a patient’s personal life. Some patients’ spouses or partners are not able to handle the stress, and they avoid hospital visits or leave altogether. Even if the partner stays, patients often feel like a burden to their partner, family, and friends. These and other psychodynamic issues must be addressed to control anxiety.

Anxiety and other symptoms that cause patients distress are treated primarily with medications. Dr. Rashid prescribes antianxiety medications such as lorazepam or clonazepam for short-term control of anxiety. If anxiety persists, she prescribes citalopram, escitalopram, or sertraline. For sleep, zolpidem or trazodone is usually prescribed. These drugs play a very important role in controlling anxiety and making patients more comfortable. Before these medications are prescribed, their possible side effects are discussed with the patients.

“My strategy is that the patient should not suffer emotionally because of pain, poor sleep, or increased anxiety. There are medications to help and to control these symptoms,” Dr. Rashid said.

Sometimes, nonmedical approaches for managing anxiety—such as breathing relaxation, guided imagery, hypnosis, yoga and exercise, and other coping strategies—can be as effective as medications, Dr. Rashid said. She talks to her patients about changing their lifestyles and encourages them to eat frequent meals that provide essential nutrition, to exercise regularly, and to get proper rest. Proper rest and nutrition improve patients’ ability to think and follow guidelines. Eating healthy gives patients more energy and reduces fatigue, which can reduce their stress and associated anxiety.

Patients with cancer, and even cancer survivors, are never completely free from anxiety. Dr. Rashid said, “They feel as though the sword is always hanging over their heads—the cancer may come back.” However, about 3 months after diagnosis, once patients understand the extent of their disease and the treatment plan, acute anxiety usually abates. Unfortunately, for some patients, depression may then set in.

Depression

Signs of depression include trouble sleeping, eating too much or too little, feelings of hopelessness or helplessness, loss of interest in life, feelings of guilt, lack of energy, and poor concentration and memory. Many of the same medications used to treat anxiety are also prescribed to control depression.

Some of these medications, such as selective serotonin reuptake inhibitors, may take 3–4 weeks to become effective. In the meantime, Dr. Rashid and the other psychiatrists in the Department of Psychiatry support patients with faster acting medications to control symptoms and with psychotherapy.

During therapy sessions, the psychiatrists work to make a connection with the patient.

According to Dr. Rashid, making a connection and commitment to their therapists may keep patients from acting on suicidal impulses. “The therapist should collaborate with the patient,” she said. “My patients make an agreement with me that they will not commit suicide, and if they feel suicidal, they have multiple coping strategies.” Sometimes, the therapist will ask the patient to fill a shoebox with pictures and mementos of good memories. When the patient feels very depressed, he or she can take out the shoebox and look through it. Making a list of coping strategies, such as walking the dog or listening to music, can also work for some patients. Dr. Rashid added that asking patients about suicide does not put suicidal thoughts into their minds; the question should be asked to determine what kinds of support patients need.

Patients with severe depression can develop psychotic features: Dr. Rashid recalled having a patient who was so depressed that the patient believed she was dead. She had this belief for almost 3 months.

Obstacles to treatment

Although only about 5% of patients who are diagnosed with cancer-related anxiety or depression have a preexisting psychiatric diagnosis, therapists find it worthwhile to ask patients about any past psychiatric problems, including psychiatric hospitalizations and history of suicide in the family. “I always ask, ‘How was your childhood?’” Dr. Rashid said. “A person’s internal reserve can be depleted by childhood trauma, including sexual or physical abuse, and about 50% of women who were sexually abused develop depression.”

For cancer patients with advanced disease, depression, anxiety, and pain are treated more aggressively. Methylphenidate can also be used to treat depression and related fatigue in these patients. Dr. Rashid said that physicians should not worry about prescribing higher doses of these medications for patients with advanced disease because controlling symptoms is the main concern at the end of life.

“If we can bring the joy back in somebody’s life, or at least help the patient live his or her life instead of having a gloomy existence, then we have accomplished our goal,” Dr. Rashid said. “Even though a person has cancer, life is still worth living.”

Steps in the Psychiatric Evaluation and Treatment of Patients at MD Anderson

1 Obtain the patient’s full history, including psychiatric and medical diagnoses; sleeping and eating habits; sources of social support; and financial, personal, or other stressors. With the patient’s permission, ask family members about any changes in the patient’s behavior.

2 Conduct blood tests to rule out physiological causes of psychiatric symptoms, such as thyroid disease.

3 Prescribe medication, if needed. Selective serotonin reuptake inhibitors (e.g., citalopram, sertraline) are widely prescribed to treat anxiety and depression. The side effects of these medications should be carefully explained to patients and their families, and patients should be advised that it takes time to adjust to a new medication.

4 Schedule a follow-up appointment to take place in 3–4 weeks, and provide patient support during the interim period, if needed. Regular follow-up is very important. Patients with depression are given a phone number to contact a counselor directly. Patients with severe depression should not stay home alone and should call a counselor or 911 if they have suicidal thoughts.

For more information, contact Dr. Anis Rashid at 713-792-7546.

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