HOUSTON--About 50% of patients function well when dealing with the
diagnosis of cancer, but the other 50% need assistance adapting to
the trauma brought on by the disease and its treatment, Debra
Sivesind, RN, said at M.D. Anderson Cancer Centers 2nd Annual
Ms. Sivesind, clinical nurse specialist in the Psychiatric Section of
the Neuro-Oncology Department, M.D. Anderson, said that she expects
patients to display a certain degree of distress in response to a
cancer diagnosis. "Patients can be expected to be fearful about
the possibility of death, disability, suffering, and disrupted
relationships," she said. "It is also natural for them to
be angry and sad at having their world turned upside-down. These are
normal responses to a cancer diagnosis that can be resolved with the
support of family, friends, and caregivers."
But, she added, when the patients distress level begins to
interfere with his or her ability to participate in treatments, make
decisions, or adapt, some form of intervention may be necessary
Oncology Nurses Play a Role in Assessing Psychiatric Illness
Debra Sivesind, RN, said in her presentation at the M.D. Anderson
Some nurses are more comfortable in the role of counselor than
Nurses must be able to elicit sensitive information that is vital to
"The quality of care is significantly compromised when the
Nurses must also be cognizant of their own feelings. She cautioned
Most cancer patients do not have a history of psychiatric problems,
Ms. Sivesind said. "About 90% of the patients who are determined
to need some type of psychiatric counseling during the course of
their disease are suffering from problems brought on by the cancer or
the cancer treatment," she said. "The other 10% have prior
One Third Have Depression
Ms. Sivesind said that about 33% of cancer patients will meet the
criteria for a diagnosis of depression. Depression is characterized
by somatic and psychological symptoms. But when diagnosing cancer
patients, somatic symptoms are not a useful measure of depression,
"The somatic symptoms of depression, which include changes in
appetite, weight loss, insomnia, psychomotor slowing, and poor
concentration, too closely resemble the symptoms of cancer
treatments," Ms. Sivesind explained.
Psychological symptoms are more dependable for diagnosing depression
in cancer patients, she said. These include depressed mood, feelings
of worthlessness, hopelessness, excessive guilt, and preoccupation
with death and suicide.
Ms. Sivesind said that signs of hopelessness and suicide should be
evaluated thoroughly because of the potential severity of these symptoms.
"For some patients, hopelessness is the realistic acknowledgment
that although there is no hope for a cure, pain relief is possible
that will allow them to spend quality time with family and
friends," she said. However, if the patients hopelessness
is related to a psychiatric disorder, this realistic viewpoint might
translate into doubts about pain control and doubts about living long
enough to enjoy time with family and friends. This form of
hopelessness is called pervasive hopelessness because it consumes and
controls all aspects of the patients cognition.
Risk Factors for Depression
Risk factors for depression amongcancer patients include a history of
depression treated through counseling or medication, a history of
alcoholism, uncontrolled pain, advanced disease, use of certain types
of medications, or concurrent illness that is typically associated
with depressed mood, for example, hypo-thyroidism and Parkinsons
Depression can be brought on by certain medical conditions as well as
by some medications. For example, metabolic abnormalities, febrile
states, anemia, nutritional deficiencies, endocrine problems, and
chronic pain have been shown to cause depressed states.
Chemotherapy agents, analgesics/anti-inflammatory drugs,
anticonvulsants (phenobarbital, phenytoin, and primi-done),
antihypertensive agents, sedatives/tranquilizers, steroids, and
stimulants are among the medications that can contribute to depression.
"We have also observed the onset of depression in patients being
treated with alpha-interferon," Ms. Sivesind said. "The
depression subsides when the dose is reduced, but then the patient
does not get the full benefit of the treatment. We have been
successful in using antidepressant therapy to counter the psychiatric
effects of alpha-interferon."
Delirium an Acute Problem
Delirium is an acute psychiatric disorder; it is usually reversible
unless the patient is in the terminal stage of illness. "Delirium
usually has a rapid onset, so it is easily diagnosed," she
said. An estimated 25% to 40% of cancer patients will develop
delirium at some point during their illness. This rate increases to
80% among terminally ill patients.
Delirium impairs thinking and memory. Primary brain tumors, as well
as up to 25% of systemic cancers, may contribute to delirium. The
most common cancers that metastasize to the brain are breast, lung,
colon, and renal cancers, and melanoma. Leptomeningeal disease can
cause direct changes in mental status as a result of tumor cells
"stealing" blood flow from the cortex of the brain, causing
local ischemia and deficits in attention and reasoning.
Radiotherapy, chemotherapy, medications, and biologic agents may
indirectly affect cognition. Ms. Sivesind described a study in which
lung cancer patients treated with prophylactic radiotherapy to the
brain suffered moderate atrophy 2 years later, and one-half had
Studies have also shown that when chemotherapy drugs are administered
intravenously or intrathecally, there is a higher risk for
neurotoxicity than when the drugs are given through other routes.
Biologic agents, such as alpha-interferon and IL-2, and steroids may
also cause delirium, as can organ failure, electrolyte imbalances,
endocrine abnormalities, and infections, particularly infections of
the central nervous system.
Depression in cancer patients is typically treated with
antidepressants and psychostimulants, the same drugs used in
medically healthy psychiatric patients.
The drug most commonly used in the treatment of delirium is
haloperidol, which has been successful in suppressing perceptual
disturbance without causing excessive sedation. Benzodiazepines have
been shown to worsen delirium, she said.
Supportive counseling is an essential form of treatment for
depression. Ms. Sivesind said the goals of counseling are to help
patients regain a sense of self-worth, correct misconceptions or
negative thinking, and integrate the conditions of their illness into
the continuum of their life experience. "We want to help
patients validate who they are, gain a sense of hope, and learn to
adapt," she said.