1. Cancer: Mental Trauma and Care
Dr. Anwar Hossain
MD Thesis Part Student
Dept. of Medical Oncology
NICRH, Dhaka.

2. Introduction:
The sound cancer mostly creates a panic environment & bites the nerves of the person, nerves of the family as well as the nerves of the surrounding society.
. It breaks the physical, psychological, social, financial as well as spiritual equilibrium of the person.
Along with the physical and psycological problems of cancer patients their care givers also go through some degree of psychological difficulties.

3. Impact of cancer:
At diagnosis – around 50% have depression/anxiety severe enough to impact negatively on their daily lives.
About 25% continue to experience distress during the following 6 months.
About (10-15)% experience symptoms severe enough to warrant intervention by superspecialists.
< 10% detected by hospital staff
If undetected = untreated = could progress to severe psychiatric illness.

4. Common psychiatric disorders associated with cancer:
Anxiety disorders: Most common psychiatric morbidity for the cancer patients is the anxiety disorders. Among anxiety disorders, generalized anxiety disorders, phobic disorder, panic disorder, panic attack or disorder, mixed anxiety and deressive disorder may be found.

5. Continued…
Depressive Disorders: About 25% of the patients suffer from Depressive disorders. Reviews showed the prevalence of depression ranges from 3-69% among the cancer patients.

6. Continued…
Adjustment disorders: About 20% of the cancer patients suffer from adjustment disorders as the disease breaks the existing equilibrium in all aspects of the patients as well as the family members.

7. Continued…
Suicide: Suicidal rate is five times more common in cancer patients than normal population and 50% suicide occurs in those who are clinically depressed.

8. Continued… Other psychiatric disorders: Affective(mood) disorders
Somatoform disorders
Substance misuse
Personality and behavioural disorders
Schizophrenia
Organic Disorders etc

9. Reaction to bad news:
Elisabeth Kubler-Ross, a psychiatrist , made a comprehensive and useful organization of reactions to impending death:
Stage 1: Shock and denial
Stage 2: Anger
Stage 3: Bargaining
Stage 4: Depression
Stage 5: Acceptance

10. Response to this reaction:
When breaking any serious illness or bad news to the patient, diplomacy and compassion should be guiding principles.
Doctors, however, should ask patients how much they want to know because some persons do not want to know all the facts about their illness and physicians should be encouraging and answering questions from patients.

11. Continued… Telling the Truth…
Physicians, however, should not hide the truth so that patients may take part in their decision of the terminal care services along with the family members.
SPIKES Protocol can be used to break the bad news:
S- Setting up the interview

12. Continued… P- Assessing the patient’s Perception
I - Obtaining the patients Invitation
K- Giving Knowledge and information to the patient
E- Addressing patient’s Emotions and Empathic response.
S- Strategy and summery

13. Taking Care: Holistic care of cancer patients:
This starts with relieving the physical symptoms, minimizing the psychological discomforts, increasing the social support by ensuring appropriate use of all available facilities.

14. Continued… Depression Anxiety and Stress
Most often s/s of these disorders are overlapping.
Depressed mood
Loss of interest(Anhedonia)
Fatigue
Loss of libido
Sleep disturbence
Lack of concentration
Irritability

15. Continued… Fear of impending disaster Suicidal thinking or attempt.
Somatic symptom like pain headache tremor fits and weakness.
Five or more for depression and three or more for anxiety.

16. Continued…
Mini-mental state examination(MMSE) can be used to asses the extend cognition.
Orientation to time- 5 points
Orientation to place- 5 points
Registration-3points
Attention and calculation- 5 points
Recall- 3 points
Language- 2 points

17. Continued… Complex command- 6 points Repetation- 1 point
Total=30 points
24-30= normal cognition
19-23= mild impairment
10-18= moderate impairment
9 or less= severe impairment

18. Management: Psycological treatment: Explanation Reassurence
Providing information regarding the disease
Rehabilitation
Psychotherapy

19. Continued… Biological or pharmacological treatment-
In management of depression & anxiety pharmacological agents also overlaps.
Short term
Benzodiazepines –clonazepam
lorazepam
diazepam
Beta adrenoreceptor antagonist- propranolol.

20. Continued… Long term with antidepressant drugs:
Tricyclics- amitryptyline, nortryptyline
SSRI-Setraline, fluoxetine
MAOI- Phenelzine
NSSRI- duloxetine, mirtazapine
Both short & long term agents should be started simultaneously from the beginning.

21. Continued…
Sometimes if any psychotic or abnormal behaviour is seen antipsychotic drugs (Chlorpromazine, Haloperidol, Risperidone,
Quetiapine) may be used.
Duration of treatment is at least 6-9 months after recovery.

22. When to refer to psychiatrist?
Severe anxiety or depression which may cause suicidal thoughts or attempts.
Resistant or poor response to treatment.
Psychotic or abnormal behaviour like hallucination, dellution, illution etc.

23. Take home message:
Every cancer patient suffers from some degree of psychiatric illness & this should not be overlooked.
Should be assesed rationally.
And has to be treated simultaneously with other primary modalities of cancer treatment for better outcomes.

24. .
THANK YOU