Information
Editors
Psychosocial Support for Patients with Cancer
Goals and components of psychosocial support
- The patient is helped to stay in control and to maintain both his/her identity and key social roles in a life situation that has been destabilised by the diagnosis of cancer and its treatment.
- After cancer treatment, the patient is helped to return to a level of functioning that is within the limits of his/her physical strength and coping.
- The components of psychosocial support encompass:
- psychiatric support; includes helping the patient to adjust, and treating psychiatric symptoms and disorders
- social support; includes supporting the patient and his/her family and giving information about benefit and insurance matters related to social security and medical or vocational rehabilitation
- spiritual support; includes exploring questions pertaining to the patient's worldview as well as existential and religious issues that occur in response to the disease.
- The practical support work is carried out by, in addition to doctors and nurses, social workers, psychologists, hospital chaplains and the multiprofessional team of a rehabilitation unit. Each professional may provide more or less extensive psychosocial support as guided by his/her training and experience.
- Cancer will create feelings of fear and uncertainty to which the patient needs to adjust. A diagnosis of cancer forces the person to acknowledge basic existential issues relating to the finiteness of human life and his/her own mortality.
- Treatment is often long and occurs in several stages, and even after the treatment has finished regular follow-ups will maintain the feeling of uncertainty about life. This psychological burden should be monitored in treatment situations and, whenever needed, the patient should be referred for additional psychological support.
- As far as the treating doctor is concerned, the holistic approach to cancer treatment can be divided into three subsections:
- the actual medical treatment of cancer
- treatment to alleviate general symptoms associated with the disease and its treatment (nausea, constipation, pain, anxiety etc.)
- a therapeutic approach that supports the understanding of bodily changes.
Therapeutic approach in clinical practice that supports understanding and control of bodily changes
- Explain the nature of the disease, and how the treatment works, thus empowering the patient to employ personal methods for symptom control and take some responsibility for the treatment.
- The patient will need education and guidance to understand body processes and perceptions as well as changes occurring in personal appearance.
- Cancer arouses fear and thoughts of doom and disaster scenarios. The patient must be able to pacify these feelings in order to remain in control and be mentally able to cope with the demanding treatment.
- Find out the patient's version of the disease by listening to him/her, analyse what you have heard based on your medical knowledge and explain - describing empathically - the fuller version to the patient.
- Before you give the patient new information, check what is the patient's current understanding of the situation (what the patient has been told before, what does he/she suspect).
- If the patient is not able to form a mental picture of the changes that the disease and treatment is going to cause, the feeling of being in control will be jeopardised and the patient faces the risk of a psychiatric crisis.
- Ensure that when being prepared for the treatment, and throughout the treatment, the patient is fully aware of the treatment plan, the aim of the treatment (curative, slowing down the disease progress, palliative symptomatic treatment) and of the adverse effects of the treatment (which symptoms are caused by the disease and which by the treatment).
- A family-orientated approach is often of benefit. Cancer treatment is long and debilitating and also affects family life in many ways (parenting, division of work, responsibilities, income).
Incidence of psychological disorders in patients with cancer
- Psychiatric symptoms that impair normal functioning occur in about ⅓ of patients.
- Fear is the most common feeling that needs to be addressed.
- Anxiety and depression are the most common symptoms.
- Adjustment disorder is the most frequently diagnosed disorder (about 60% of all disorders that are serious enough to need diagnosis).
Who needs support?
- Providing adequate information about the treatment and an approach that encourages mentalisation are beneficial to all patients.
- More comprehensive support measures are required by 10-30% of patients.
- The need for special support may be greater in the following situations:
- challenging disease
- Advanced disease at diagnosis
- Poor prognosis
- Treatment causing a multitude of adverse effects and/or complications
- challenging life situation
- Parents with young children
- A young adult just leaving home
- individual differences in the proneness to anxiety and ability to cope with uncertainty.
- For example, controlling, demanding and perfectionist personality traits, tendency to worry beforehand, emotional instability.
- Within the healthcare system the support is delivered as part of the patient's physical care and by specialist support service providers: social workers, psychiatric nurses, psychologists, psychiatrists, hospital chaplains etc.
- The support should be based on good physical care, which includes delivering treatment information and education to the patient.
- The care relationships should be such that the carer is willing and has time to go through the patient's feelings about the disease, leading hopefully to the easing of thoughts of doom and disaster scenarios that the patient may harbour.
- The aim should be to create an environment of two-way communication which will empower the patient to take responsibility for the treatment, tolerate the inevitable disappointments and frustrations associated with the treatment and be motivated to comply with the care instructions. This will enable even demanding treatment regimens to be carried out on an outpatient basis.
- Management of matters related to the social security of the patient and his/her family
- Consult a social worker!
- Check the reimbursement status of medication and which medical certificates are needed.
- Sick leave, application for rehabilitation grants and which medical certificates are needed.
- Applications for care allowances and which medical certificates are needed.
- Support to affected parents. Check
- whether the everyday life of the family is carrying on normally, is the family unit able to provide sufficient care for the children?
- what is the atmosphere within the family, do the family members share the same understanding of the parent's disease?
- whether the parents are prepared to talk about the disease with the children without losing their parenting role?
- If any problems are identified, advise the patient to contact, for example, the school nurse, school psychologist, welfare officer or family guidance centre.
- If child care is anticipated to become problematic, advise the parents themselves to contact local child welfare officials.
- Outside the healthcare system, psychosocial support is delivered by various cancer organisations.
- This support covers general advice as well as various courses providing either a basic overview of the disease or adjustment training focusing on post-treatment rehabilitation.
- Local cancer organisations publicise their courses and assist with applications.
- In some cases, a medical certificate is required.
- The starting point should be a properly conducted diagnostic evaluation which should assess the seriousness of the disorder.
- Normal adjustment (e.g. the patient is openly upset and has short-term changes in mental alertness, emotional state and mood in line with the prevailing physical state)
- Psychological stress reactions
- Adjustment disorder (F43.2: emotional disturbances and anxiety states triggered by the diagnosis, impairing the person's social functioning; the symptoms do not fulfil the diagnostic criteria of a more serious psychiatric disorder)
- A more serious psychiatric disorder
- Treatment is carried out in accordance with the care guidelines issued for the particular psychiatric disorder.
- In mild cases, it often suffices to offer supportive talk therapy sessions with a focus on a therapeutic approach (for example, 1-6 sessions). It is important that the person giving talk therapy is aware of the type of cancer and is able to discuss and correct the patient's version of the disease.
- In more severe cases, medication may initially be needed to restore the psychological functioning to a level where talk therapy may be of benefit.
- Treatment must acknowledge the role of cancer as the possible trigger or maintaining force of the symptoms.
- Using a psychological approach and focusing on the patient's mind, the supportive talk therapy should concentrate on these themes.
- Cancer and its treatment may - as an organic/biologic factor - be the cause behind the psychiatric changes and symptoms; this must be taken into account when counselling the patient and prescribing medication.
Drug treatment of psychiatric symptoms in cancer patients
- Drug interactions must be borne in mind during simultaneous active cancer treatment.
- Cytotoxic chemotherapy suppresses the bone marrow (leucopenia, increased bleeding tendency) and alters the functioning of the liver enzyme systems. These effects must be considered when choosing antidepressants or antipsychotics.
- Glucocorticoids predispose the patient to the antidepressant-induced effects that cause hyperarousal and insomnia.
- Anti-oestrogenic and anti-androgenic treatments (breast cancer and prostate cancer) may affect the mood and sleep patterns.
- Interferon (melanoma and kidney cancer) predisposes to depression and may cause cognitive slowing, which will reverse when the medication is withdrawn. Depression can usually be treated with antidepressants.
- Safe medicines to be used concomitantly with cytotoxic drugs are, if indicated, anxiolytics, e.g. lorazepam and oxazepam.
- The regular and long-term use of an antidepressant warrants careful consideration (drug interactions). The initial adverse effects of the medicine may be enhanced by concurrent cytotoxic chemotherapy, but, on the other hand, the treatment of depression may help the patient to endure the demanding cancer treatment.
Short-term treatment (1-4 weeks) of anxiety and insomnia
- The drug therapy to treat insomnia should be chosen according to the type of the sleep disorder (sleep-onset insomnia, nocturnal awakenings, waking too early in the morning).
- Zolpidem 10 mg, effective in initiating sleep
- Zopiclone 7.5 mg, effective in initiating sleep
- Oxazepam 15-30 mg, nocturnal awakenings, also waking too early in the morning (if a sign of depression, consider starting an antidepressant)
- Temazepam 10-20 mg, nocturnal awakenings
- Daytime anxiety
- Psychotic symptoms
- Anxiety/agitation/restlessness
- Haloperidol 0.5 mg + lorazepam 0.5 mg 3 times daily, a useful combination during cytotoxic chemotherapy
- Insomnia and hyperarousal caused by glucocorticoids
- Firstly, try medication recommended for insomnia and daytime anxiety
- If they are not sufficient, try quetiapine 25-100 mg in the evening.
- Longer lasting insomnia and/or anxiety
- Is the patient suffering from a more severe anxiety disorder, depression or a prepsychotic state?
- If so, the treatment guidelines given for the particular disorder should be followed.
- The choice of an antidepressant should be based on the special features of the psychiatric symptoms and the adverse effect profile of the drug.
- Antidepressants with sleep enhancing properties
- Benefit mediated through 5HT2 receptor antagonism, antihistamine activity
- Mirtazapine
- For insomnia 7.5-15 mg in the evening
- Treatment of depression 30-45 mg/day
- Improves appetite
- May alleviate nausea
- Promotes weight gain
- Risk of agranulocytosis
- At the doses used in insomnia may be combined with SSRIs.
- Mianserin
- For insomnia 10-30 mg in the evening
- Treatment of depression 60-90 mg/day
- The action profile is similar to that of mirtazapine, but mianserin does not promote weight gain to the same extent
- Risk of agranulocytosis
- Antidepressants with anxiolytic properties
- Benefit mediated through 5HT2 receptor antagonism and 5HT1A receptor agonism
- Nausea, anorexia
- Benefit mediated through 5HT3 receptor antagonism (cf. ”setrons")
- Antidepressants with pain threshold increasing properties
- Enhance the spinothalamic activity of serotonin and noradrenaline neurotransmitters in the descending inhibitory pain pathways.