Psychological support

• Diagnosis of malignancy should be communicated to the patients and their family without delay.
• Information should be communicated in a quite area with privacy, ideally in a company of close relative.
• Give time to patient and relative to ask appropriate questions.
• Patient should be made aware of clinical studies.
• Treatment plan must be clearly written, so that patient understands it and also other members in multidisciplinary specialist team.
• Give written information about disease.
• Gain trust of patient and immediate family from the outset so that they can understand  and accept the need for proposed intensity and duration of treatment and the risks of complications
• A relationship of mutual and complete openness should be established as soon as possible, and questions and discussion must be encouraged.
• Fear of failure of therapy may be lessened by remission, but the patient’s anticipation of the complications of subsequent cycles of therapy may add to their psychological problems. Clinical team must deal with these problems before patients suffer significant and lasting harm.
• Withdrawal of anticancer treatment may be seen by many patients as a severe blow to morale, it must be continued in one or the other form.

Psychological problems

Depression

• Seen in 50% of hematology patients
• Clinical features: depressed mood, feelings of guilt or worthlessness, inability to concentrate, decreased energy, preoccupation with death/suicide, changes in eating habits, changes in sleeping patterns
• Drugs causing depression- Prednisolone, dexamethasone, procarbazine, vincristine, vinblastine
• Treatment:
  • Counselling by oncologic psychologists
  • Antidepressants: Continue for 6 weeks after symptoms subside
    • Citalopram- 20-80mg-PO-OD
    • Imipramine
    • Amitriptyline
  • Psychostimulants
    • Methylphenidate- 5mg- PO- at 9am and noon

Anxiety

• Causes:
  • Worries about future (Uncontrolled symptoms, family concerns, concerns about death)
  • Isolation from loved ones
  • Sepsis, hypoxia, metabolic abnormalities
  • Withdrawal from alcohol, opioids, benzodiazepines
  • Drug reaction- Ex: Akathisia from metoclopramide
  • Uncontrolled pain
• Treatment:
  • Tab. Lorazepam- 0.5-2mg- TDS
  • Psychotherapy

Delirium

• Can result in agitation, paranoia, fear, insomnia, daytime somnolence, nightmares, restlessness, irritability, distractibility, hallucinations, delusions
• Causes: 
  • Metabolic abnormalities- dehydration, hypernatremia, hyponatremia, hypercalcemia, hypocalcaemia, uraemia, ,hyperglycaemia, liver failure
  • Drugs- Opioids, radiation, chemotherapy, benzodiazepines, TCA etc
  • Others- Brain metastasis, paraneoplasticsyndrome, malnutrition, hypoxia, fever, infection, uncontrolled pain
• Strongly associated with mortality- occurs in 80% of dying patients
• Treatment:
  •  Remove delirium causing medications
  • Inj. Haloperidol (Seranase)- 0.5- 1mg- every 1-2 hrs- IV/SC (Not to exceed 20mg in 24hrs)- then maintain on an effective dose divided into BD, then slowly taper over 2 weeks. To be given with/without Lorazepam- 0.5-1mg- IV
  • T. Quetiapine 25-200mg- PO- HS
  • If no response after 24-48hrs- Inj. Chlorpromazine- 12.5-50mg- IV- can be repeated every 1-4hrs till patient is sedated
  • Non pharmacological measures: Make patient's surroundings as familiar as possible, restore aids of hearing and sight, reorient the patient frequently, have family members/friends/well-known care givers present

Insomnia

• Often occurs due to pain, medications, anxiety or mood disorder
• Distressing problem for cancer patient
• Can make anxiety/ delirium/ pain worse
• Treatment
  • T. Zolpidem- 5mg- HS
  • T. Lorazepam- 0.5-2mg- HS

Factors that predict poor coping in patients with cancer:

• Past psychiatric history
• Compliance issues
• Younger age/ female sex
• Limited social support
• Recent history of smoking cessation
• Substance abuse history
• Recent losses/ Financial problems
• Advanced disease
• Uncontrolled symptoms
• Pessimistic outlook to life
• Multiple obligations
• Higher regimen related toxicity

Indications for referral to psychiatrists:

• History of psychiatric illness
• Persistent non-compliance
• Persistent symptoms unresponsive to above treatment
• Abrupt unexplained change in mood or behaviour
• Unusual eccentric behaviour or confusion
• Complex family issues

Note: 

• Care givers and families also share similar degree of psychological disturbance
• Following are useful for patients and their family
  • Providing information at every contact, making them understand the facts and treatment options. 
  • Social worker with good communication, empathy, listening skills, who can provide emotional support.
  • Support groups
  • Music and art therapy
  • Spiritual support- It can be source of great strength or considerable pain to the patient. Hence should be used cautiously.
  • Mind-body therapies- Yoga, meditation etc.