From OncoLog, August 2012, Vol. 57,
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
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
“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.
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
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
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.
information, contact Dr. Anis Rashid at 713-792-7546.
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