Psychiatric oncology: Cancer in mind

Abstract

Psychosocial oncology is an upcoming area of interest, which deals with numerous psychiatric, psychological, and social aspects of malignancies. Psychiatric oncology relates to some of the common psychological and emotional problems encountered in persons with malignancy and their formal and informal caregivers. This oration will discuss the importance of this field of Consultation Liaison Psychiatry, with a focus on the research and practice in the Indian setting. This presentation will also share the findings and researches of the presenter. All these range from studies on cancer pain and palliative care, screening for psychiatric morbidity, quality of life, communication skills for health professionals in breaking bad news and handling difficult questions, and counseling. The findings on researches on somatization and illness behavior in cancer patients would highlight newer challenges in this field. Caregivers of persons with cancer are as important as the patient, but usually ignored. The stress, strain, burden, positive emotions, and coping in the context of care giving for persons with cancer are being increasingly realized. Professional caregivers should be aware of caregiver difficulties and support them through their ordeal. Lastly, the importance of dealing with staff stress and burnout among health professionals looking after families with cancer patients and survivors will be emphasized.

I would like to begin with paying my tributes to a visionary, Dr. DLN Murthi Rao, in whose memory this oration has been instituted. Dr. Murthi Rao graduated from Mysore, did DPM from England, and was trained at Institute of Psychiatry, Maudsley, Belmont, and St. Ebbes hospitals. He joined the All India Institute of Mental Health (AIIMH, currently known as the National Institute of Mental Health and Neurosciences, NIMHANS), Bangalore, as Junior Professor and later as Professor and Director AIIMH from 1960 to 1962. He was an active member of many professional bodies and an advisor to the Government of India and the ICMR. He had a role in the setting up of the Shahdra Mental Hospital (currently known as IHBAS, New Delhi). He also set up the Association for Mental Handicap near NIMHANS, Bangalore.

My choice of this topic on Psychiatric Oncology is based on this being a passionate area of my interest. We are all aware that cancer affects the individual, his family, professional and social life. And there is a vast role of psychiatry in so many aspects of cancer. Psychological distress in cancer is considered as the sixth vital sign. Moreover, a study of psychiatric oncology throws light on phenomenology and understanding of psychiatric disorders and their management. I am inspired to work on this area by a number of individuals, most importantly Dr. Jimmie Holland, a pioneer in this area whom I met and associated for a while in 1986 at the Memorial Sloan Kettering Cancer Centre, New York, and the Late Dr. Pete Maguire, whom I met in 1988 and had my training in Psycho Oncology at the Cancer Research Campaign, Christie Cancer Hospital, Manchester, UK, under the Commonwealth Medical Fellowship Program. This Oration focuses on Psychiatric Oncology with special reference to India and is based on the work at NIMHANS.

INTRODUCTION

Psychiatric oncology is the study of psychiatric and psychosocial aspects of cancer, which may be related to the development, course, or outcome of cancer. Psychiatric oncology as a sub-specialty focuses on a number of issues, which include the role of life events, stress, and other psychological factors in the causation, maintenance, and prognosis of cancer; psychological and emotional reactions to diagnosis of cancer, its recurrence, metastasis; psychiatric disorders in relation to cancer and its treatment; psychological methods of treatment, and counseling, communicating with cancer patients and their relatives; terminal care and palliative care; study and management of grief and bereavement related to cancer; and staff stress and burnout among professionals treating cancer patients.[1]

STRESS AND CANCER

The role of stress and life events in etiology, maintenance, prognosis, and survival has been an area of intense work, debate, and controversy. Over years there is accumulated evidence on the role of major life events preceding relapse and recurrence of breast cancer. Studies have documented an onset of a malignancy or a recurrence following bereavements. These findings on possible mechanisms can be best understood through Psycho-neuro-endocrino-immunological mechanisms. This mechanism also forms the basis of explanation for benefits from psychosocial care of cancer patients.

Psychological and emotional reactions

The common psychological and emotional responses to cancer arise from knowledge of life-threatening diagnosis, its prognostic uncertainty, and fears about death and dying. The emotional responses are also due to physical symptoms—pain, nausea, lymphoedema, and other distressing symptoms of the disease and unwanted effects of medical, surgical, and radiation treatments. The stigma due to cancer and its consequences adds to the negative reactions to the disease.

Although the different coping methods described in Western literature are also noted in Indian patients with some modifications and variations, the common coping methods noted in our studies in Indian settings have been denial, resort into religion, putting it on to fate / karma, and sheer helplessness. Using these mechanisms, however, resolution was noted in less than 40% of the frequent concerns.[2]

Psychiatric morbidity in cancer patients

The most common psychiatric disorder observed in cancer patients is adjustment disorder with depression, anxiety, or both. A patient with cancer is expected to have a certain level of psychological distress, which is considered a natural reaction, more often than should be. However, there is definitely an underreporting of psychological morbidity among cancer patients.

A majority of the studies have revealed a significant level of psychiatric morbidity among cancer patients. Generally, these studies found adjustment disorder as the most common psychiatric syndrome in cancer patients with major depression, delirium, and anxiety disorders as the next common diagnoses. Conditions like personality disorders, psychoses, and substance abuse are comparatively infrequent. In the Indian setting, 38%[3] to 53% of cancer patients were found to have identifiable DSM-III-R psychiatric disorder. In a large study including 903 cancer patients attending a hospice, a general hospital, and the neurosurgery department of NIMHANS, psychiatric disorders were identified in 48%, of which 44% had adjustment disorders,[4] whereas the prevalence of psychiatric disorders in a cancer hospital was 53% (depressive disorders 22%, sleep disorders 15%, adjustment disorders 9%, mixed anxiety depression 6%, and anxiety disorders in 1%).

ADJUSTMENT DISORDERS

These are the most common psychiatric syndrome seen in cancer patients. Derogatis et al.[5] reported its prevalence as 68% in their study population. A majority of the patients were found to have adjustment disorder mainly with depressed mood, anxious mood, and mixed emotional disturbances.

MAJOR DEPRESSION

Depressive symptoms can be caused by the disease process directly or by the various chemotherapeutic agents used for the treatment of cancer. Depression can also occur as a functional response to the disabilities. Feelings of worthlessness and guilt were found to be powerful discriminants between normal sadness seen in cancer and major depression. Studies reporting prevalence of depression vary on methodological aspects and vary from 1.5% to 50% (mean 24%; median 22%). The prevalence of depression in cancer patients also varies with cancer site, clinical course, type of treatment, and presence of pain. The prevalence of major depression in cancer patients, on an average, ranges from 13% to 40%.

There are certain problems associated with diagnosing depression in patients with cancer. Firstly, depressive symptoms are natural to occur in the context of the severe stress of having a serious medical illness like cancer; secondly, many physical/somatic/ vegetative symptoms of depression are similar to those of cancer, for instance, the diagnostic criteria for major depression in the DSM-IV include a number of symptoms which are frequently attributed to the malignancy, e.g. loss of appetite, loss of weight, insomnia, loss of concentration, and loss of energy. The occurrence of somatic symptoms, especially non-organic somatic symptoms, creates certain problems in the diagnosis and management of depressive disorders in cancer. Thirdly, a number of diagnostic systems have used different methods to diagnose depression to overcome the problems raised due to symptoms common for depression and cancer, like substitution of somatic symptoms with psychological ones, omitting somatic symptoms, changing the number of criteria to be met, or trying to differentiate if the symptoms are due to the disease or due to psychological factors.[6–9]

A number of risk factors have been identified which tend to make the cancer patients vulnerable to develop depression. Young age, females, palliative treatment, severe physical symptoms or uncontrolled pain, advanced disease, and marked disability or discomfort is some important risk factors. Other risk factors are social isolation, recent life events or losses, a tendency towards pessimism, socioeconomic pressures, and history of substance abuse, alcoholism, mood disorders, or suicidal attempts.

DETECTION AND SCREENING

In the crowded cancer hospital clinics, it may be difficult to do detailed assessment of every patient and all relatives. For rapid assessment of psychiatric morbidity in cancer patients, the Hospital Anxiety and Depression Scale (HADS)[10] has been adapted to test Indian cancer patients. The cutoff score of 7 on the Anxiety subscale gives a sensitivity of 87% and specificity of 79%; for Depression subscale the cutoff score of 8 gives a sensitivity of 75% and specificity of 76%. If one uses the total scale scores, the cutoff of 16 gives a sensitivity of 85% and a specificity of 88%.[3] The HADS scale, though simple and convenient, has problems for use among Asian populations and with its factor structures.[11,12]

The Coping and Concerns Checklist developed in Cancer Research Campaign's Cancer Research Centre and adapted for use in India,[2,13] helps in detecting common physical and psychosocial problems in cancer patients. In the NIMHANS study, 90% of cancer patients had at least one concern, of which 44% had one to three concerns and 46% had four or more concerns. The common concerns needing support and not needing support are given in Table 1. Relationships with partner or others, support from family, sexual role were only occasionally reported as concerns, in keeping with the socio-cultural, traditional and familial ties, bonds, and relationships. These could also be a form of denial of these concerns, as it is not socially acceptable to complain of these issues.

Table 1.

Common concerns in Indian cancer patients

Interestingly, the concerns were noted to be similar in Bangalore and Manchester[14,15] except financial concerns, which were more often noted in cancer patients in Bangalore.

ANXIETY DISORDERS

Anxiety can also be a part of the normal stress response, adjustment disorder, and delirium. Generalized anxiety disorder is not as frequent as depressive disorder in cancer patients. Anxiety symptoms can be reported as a part of depression in cancer patients. The common anxiety symptoms noted in cancer patients are persistent tension and worrying, panic attacks, and palpitations. The worries are about future, family, finances, relapses and recurrences, and survival. The worries can be elicited using the Coping and Concerns Checklist, mentioned above.

A number of patients have post-traumatic stress disorders (PTSD) like experiences in relation to discovery of abnormal growth, breaking of bad news, and the hospitalization and treatment experiences. Patients get distressing memories, flashbacks of unpleasant experiences, panic attacks, and arousal symptoms.

Somatization and illness behavior in cancer

Somatoform symptoms are noted in patients who have recovered from their disease or those who have residual disease. These are in the form of fatigue, tiredness, and pain. These take the form of an abnormal illness (AIB) behavior and are usually misinterpreted by the patients as signs of the disease recurrence, relapse, or metastasis and spread of the disease. Presence of a somatoform disorder in cancer can create management problems resulting either in delaying the treatment or over treating somatoform symptoms.[16,17]

Presentation of AIB in cancer may manifest as unexplained somatic symptoms, persistent fatigue, tiredness in disease-free cancer patients, pain, and abnormal sensations. Studies have described residual, persistent fatigue in survivors of childhood cancer, survivors of Hodgkin's disease and cancer patients referred for psychiatric consultation,[16,17] and fatigue in recovered disease-free cancer patients.[17–19] The observation of this phenomenon draws attention to the occurrence of medically unexplained symptoms in medical diseases.[19]

In a study conducted during my Commonwealth Fellowship at Christie Hospital and Cancer Research Campaign, Manchester, common somatic complaints in a study were sensory symptoms (30%), tiredness or exhaustion (30%), multiple symptoms (27%), weakness (22%), reduced energy (19%), pain (19%), and fatigue / lethargy (17%). In this group, depressive disorders were diagnosed in 53%, anxiety disorders in 12%, and atypical somatoform disorders in 27% of the cancer patients; somatic concern and preoccupation were noted in 40%. It was observed that somatic symptoms in cancer were inter related in such a way that one somatic symptom could cause other somatic symptoms, e.g., pain causing fatigue. It was also noted that patients may tolerate somatic symptoms differentially. Alexithymia features were apparent in 17%. During follow-up, somatisers with depression showed clinical improvement whereas those with atypical somatoform disorder showed no improvement or deteriorated.[16–19]

The etiology of somatization in cancer is not fully understood. The etiopathogenesis includes both organic and psychological factors. Somatic symptoms could be related to anxiety and depressive disorders. It is also likely that the experiences of somatic symptoms may be exaggerated due to emotional factors and due to somatization, physical complaints may be increased or persistent. The somatic symptoms may be related to secondary alexithymia (secondary to the diagnosis of cancer). Lastly, as discussed above, somatic symptoms could be a manifestation of abnormal illness behavior.[19]

The clinical implications of somatization and abnormal illness behavior in cancer are significant. Firstly, it is difficult to decide whether certain physical symptoms are due to cancer, chemotherapy, radiotherapy, surgery, psychiatric disorder, or illness behavior. Secondly, somatic symptoms magnify disability resulting from cancer and interfere with treatment adherence and decisions cause delay in recovery. Thirdly, these symptoms result in poor outcome and recurrence, and reduce overall wellbeing and quality of life (QOL). Lastly, it is known now that these physical symptoms in disease-free cancer patients respond to antidepressants and psychosocial intervention.[19] It will become an error of clinical judgment, if these somatic symptoms and physical distress are treated as signs of progression of the disease with chemotherapy, radiation treatment, or opiates.

Anticipatory nausea and vomiting (conditioned response to chemotherapy)

The conditioned response side effects are thought to develop through a classical conditioning. These conditioned responses can occur before, during, or after chemotherapy. Patients start experiencing anticipatory nausea even to the sight of the hospital, ward, staff, and of course, the treatment room. In some cases, it started early morning, at home, before even starting for the hospital, or awaiting the chemotherapy.

Impact of awareness of diagnosis

Diagnosis of cancer evokes far greater emotional reaction than diagnosis of any other disease, regardless of mortality rate or treatment modality. Shock and disbelief are the most common initial responses, followed by anger, depression, and a feeling of loss and grief. The normal reaction can vary from person to person. The intensity and duration of emotional distress and the degree to which it interferes with patient's life seem to determine whether the emotional response is normal or abnormal.

The other common emotional reactions in patients diagnosed to have cancer are denial, anxiety, guilt, and depression. As mentioned above,[2] in Indian patient's denial, resort into religion, putting it on to fate/karma and sheer helplessness are common first reactions to the diagnosis. The major sources of continuing emotional distress are fear of incurability, pain, disfigurement, recurrence of disease, and a sense of helplessness over its treatment. Cancer may affect the family in a similar way as it invades the body of the patient and cause psychosocial, or anxiety and depression in them.

In one of our studies,[20] it was surprising to note that, even in patients attending a cancer hospital for treatment, the awareness about diagnosis was noted in 54%, whereas 46% were unaware that they had cancer, though they were regularly coming for treatment and were aware about the name of the cancer hospital. Similarly, 45% of patients had awareness about the nature of treatment whether it was curative or palliative. However, there was no difference between the two groups in patterns and prevalence of psychiatric morbidity. There have been conflicting reports about the relationship between awareness of diagnosis and psychiatric morbidity, with some research showing that those who are aware that they have a cancer disease are more likely to have increased psychiatric morbidity, in contrast to other studies, which indicate that those who are unaware of the diagnosis are less likely to have psychiatric problems. However, in our study, more patients in the “unaware” group refused treatment for psychological distress.[20]

Morbidity associated with treatment modalities

The three forms of treatment available, surgery, chemotherapy, and radiotherapy are associated with psychiatric morbidity. Psychiatric morbidity associated with cancer therapies range from 18% to 40%.

Radiation treatment (RT) is associated with highly unpleasant side effects. The side effects include nausea, vomiting, and increasing fatigue. The unpleasant fatigue usually seen in radiotherapy patients had a high correlation with psychiatric morbidity. In an prospective study on levels of anxiety and depression in patients receiving radiation treatment in a cancer hospital in India,[21] anxiety and depressive disorders were detected frequently both prior to treatment and later during follow-up. Frequency of anxiety increased significantly after initiating RT, but later reduced during follow-up assessments after a few months. Similarly, subjective wellbeing changed as the radiation treatment progressed.[22]

Chemotherapy can produce nausea and vomiting as immediate effects. Although various chemotherapeutic agents vary in this emetogenic potency, almost all have side effects. After an initial episode of nausea and vomiting 15% to 65% of patients develop anticipatory nausea and vomiting, discussed above. Sometimes, it becomes so severe that they cannot continue treatment. Patients may also develop a conditioned response when exposed to sights and smells reminiscent of chemotherapy experience. Most often prolongation of life is achieved at the cost of QOL. Most of the studies in this area, which judge outcome solely on the basis of survival ignore QOL and psychiatric morbidity.

Psychiatric aspects of palliative care

Advanced cancer is associated with increased psychiatric morbidity for mainly three reasons—(i) physical symptoms like pain, nausea, vomiting, and weakness cause emotional distress, (ii) fear of death, and (iii) disease process or its spread and metastasis may directly produce psychiatric problems.[23]

Psychiatric aspects of palliative care include detection and management of emotional and psychological problems, pain relief with oral morphine, especially correcting myths related to addiction to morphine in cancer patients and checking for “pseudo addiction.” The psychiatric care also includes methods to provide symptom relief, attention to QOL, spiritual concerns and spiritual QOL, and care of terminal stages and the terminally ill. The lack of support for the dying patient/families needs to be addressed.

One highly stressful and significant part of care is the communication issues and problems. Talking about death with a terminally ill person or the family can be truly challenging. Dealing with psychological problems has been found to be more stressful than dealing with physical problems. Staff members with higher death anxiety face difficulty in dealing with death of their patients. Most palliative care staff members wonder what to talk about in such a situation; whereas, it is active listening to the terminally ill person or the family, which is satisfying to the patient, relative, and the staff.[24,25]

The difficulty increases when the terminally ill person expresses about desire for death. In a study on the prevalence and severity of desire for hastened death and its association with demographic, psychiatric, psychosocial, cancer variables, using the Desire for Death Scale,[26] in 191 cancer patients, from neuro-oncology: 111, Radiotherapy 22, Hospice 58, No desire for death was reported by 64 (34%), slight desire by 47 (25%), mild desire by 57 (27%), moderate desire by 13 (7%), and extreme desire by only 3 (2%) patients. The desire for death was more in widowed, divorce; more in chest/abdominal cancers; more in hospice patients and more in those with a longer duration of illness [Terry Fox Project 2000-2003 Report].[4]

Communication skills in cancer

One of the most difficult, challenging, and exciting role of a psychiatrist in cancer care is dealing with issues related to communication skills of health professionals. Health professionals dealing with cancer patients find it difficult to disclose diagnosis to cancer patients and their relatives. Breaking bad news is a skill which most doctors and nurses are not trained in, and this is an integral part of cancer care. Psychiatrists are called upon to train cancer specialists in skills of breaking bad news.[27] However, one should remember that breaking bad news skills do not make the bad news good, but soften the impact of the same, and give an opportunity to deal with the impact of delivering bad news, and encourage expression of feelings by the patients and relatives. Dealing with “Collusion” is another challenging situation, especially in traditional societies like ours, where family is an important part of care providing. Family members urge the doctor not to discuss diagnosis with the patients, due to fear of upsetting the patient, while the patient aware of the diagnosis does not want this to be shared with the family members due to a similar fear.[28] Dealing with collusion and breaking collusion sensitively is important to maintain trust and communication between patient and family members without the conspiracy of silence. Handling difficult questions like, what will happen in future, will one become alright, how long will one live, “Why me ?!” and talking about death and dying.[25]

Training of cancer specialists and professionals has been done through workshops on effective communication skills using Peter Maguire's model – which involves exciting methods like interactive discussions, role plays, video demonstrations, and many other different teaching methods to impart skills and knowledge on effective communication.

Psychopharmacological management

It has been reported that antidepressants are grossly underused in cancer patients, for fear of addiction/dependence, caution against adverse side effects, and drug interactions. Another reason for this underuse is depression in cancer patients is a natural reaction and will disappear with time, without antidepressants![29,30] There are several reports on efficacy of antidepressants in depressed patients with major physical disorder and on the usefulness of antidepressants in cancer patients with depression. The agents that can be considered for use in cancer patients are: tricyclic antidepressants, newer antidepressants, like specific serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOI), sympathomimetic stimulants, lithium carbonate, and alprazolam.

Relaxation techniques like muscle relaxation, relaxing imagery and hypnosis may also be useful in the treatment of conditioned response to chemotherapy, anxiety, and panic attacks.

Principles of psychological management

The principles of psychological management include sensitive breaking of bad news, providing information in accord with person's wishes, permitting expression of emotions and feelings, clarification of concerns and problems, encouraging confiding ties, involving patient in decisions about treatments, and setting realistic goals. The psychological management should be an appropriate package of medical, psychological, spiritual, and social care.

The methods of psychological management are psychological therapies—individual or group, counseling, cognitive behavior therapy, behavior therapy—desensitization, rehabilitation, and mindfulness. Complementary or alternative therapies are also reported to be useful in individual cases. Self-help groups and volunteer support groups for cancer patients and their families are also reported to be useful.

Psychological interventions with its emphasis on fostering a positive attitude, helping the patients to comply and cope with the treatment and reducing emotional distress, can in fact compliment the traditional medical treatment. Many of the patients who suffer from cancer related psychiatric problems do not receive any professional help because physicians rarely ask patients about their emotional well-being and patients are reluctant to disclose their distress.

During psychological intervention for cancer-related problems, it should be acknowledged that a cancer patient, after all, is a psychologically normal individual under severe stress. Hence, the therapy should be brief and directed towards current problems. There should also be an active attempt to identify and make use of the personal strengths.

During counseling the cancer patient, the therapist should be on a look out for “cues” of emotional distress which are likely to be given out by the patient. The aim is to optimize patient to disclose his distress or facilitate emotional expression. The counseling sessions may achieve three levels. First, in which the patient will give a lot of information about the physical condition, physical symptoms, family, or other issues, but not anything about emotions. Second, in which the patient besides giving information about physical aspects may talk about emotional distress, but would not express or show the feelings. The third level would have not only information about physical and psychological aspects, but it would also have the expression of emotional distress. The therapist should attempt to achieve this third level to be effective in his role.

Quality of life in cancer

The phrase QOL perhaps became popular and in common use due to the chemotherapy of cancer patients, which promised to increase survival, but at the cost of severe and unbearable adverse effects and toxicity. Public and professionals started questioning if such a life was worth it!

Many definitions of QOL have been proposed and there are many measures, scales, and instruments to quantify the subjective QOL. Common scales for use in India are the HADS, EORTC, Rotterdam's Symptom Check List, WHOQOL – 100, Bref, Functional Assessment for Cancer and therapy (FACT, FACIT), EuroQOL, EQ - 5D to name a few. Interestingly, most of these scales and measures focused on functioning level of the person and objective elements of QOL.

In a study on what is important for QOL for Indian patients of cancer, it was noted that satisfaction with functioning rather than functioning was more important. Further, peace of mind, spiritual satisfaction, and social satisfaction were considered to be very important by nearly two third of the subjects. Individual's functioning and levels of physical and psychological health were given much less significance. Level of satisfaction was valued much higher than the level of functioning.[31]

Due to non-availability of a satisfactory measure of QOL for cancer patients in India, the relationship between number of concerns and QOL was explored and it was noted that the number of concerns was a clear indication of poorer QOL. It was replicated that the numbers of key concerns indicate the QOL. Cancer patients in general hospitals had 2.6 concerns, where as cancer patients in a Hospice had on an average of 4.7 concerns. QOL was poorest among the hospice patients as expected. On the positive side, QOL improved following interventions.

Can psycho oncology make an impact on psychiatric care of cancer patients?

This is an important question to be asked that whether the knowledge of psychiatric oncology made any significant affect on the psychosocial care of cancer patients and their relations, or is the discussion only of theoretical importance. As mentioned above, many studies have been carried on, on psychosocial aspects, which have guided and made a difference to care of cancer patients.

A significant contribution of psycho-oncology is in improving and maintaining QOL by psychiatric methods including effective communication skills, mainly active listening, having effective ways of breaking bad news, handling difficult questions, dealing with emotions and counseling. The research on psychiatric oncology has established ways of detection of psychiatric morbidity using standard measures like the HADS and necessary modifications in the diagnostic criteria to make a diagnosis of depression by modifying the diagnostic criteria. The identification of psychiatric morbidity in cancer patients led to effective treatment of psychiatric disorders.

Researches on psycho-oncology also helped improving QOL through cancer treatments by helping cancer patients and their families making choices—the choice between radical and conservative surgery, the use of prosthetic techniques, care of colostomies, reducing myths about radiation treatment, and efforts to reduce toxicity like, nausea, vomiting, alopecia through behavior therapy, medications and counseling, pain relief and symptom control and reduce financial burden, and hospitalization through social support.

An important and often neglected area of psychosocial oncology is staff stress and burnout among physicians, nurses, and cancer professionals. Increased staff stress and burnout has been found to be related to problems of communication and relationships, difficulty in taking conflicting decisions, breaking bad news, and handling difficult questions, repeated confrontation with difficult and delicate situations. Staff stress is also related to a realistic work overload, poor administrative support for social support, decision making, work involvement, setting unrealistic objectives, and admission of dying patients.

PSYCHO-POLITICS OF CARE

There are some tricky issues in the multidisciplinary psychosocial care, like who should provide which aspect of care? Should cancer centers have a psychiatric oncologist like the medical/surgical/radiation oncologist. Most cancer specialists are under the impression that communication has to be handled by mental health professionals, whereas the patients and families expect this to be done by their primary and main specialist. The cost of care is another issue, which the patients, families, and the staff have to decide. Similarly, what should be QOL—quality of surgery or satisfaction with life? is another theme where there is a difference of opinion between specialists, and families. Satisfaction of patients/families is often not assessed and unheeded. Morphine availability in palliative care has been a challenge in the country. There is marked unavailability of oral morphine for pain relief for cancer patients, and in hospitals and hospices. For mental health professionals, it is important to reassure other colleagues and public that such oral morphine given for cancer pain relief is not related to dependence or addiction. Psychiatrists also need to educate other health professionals about “psuedo addiction.”

ETHICAL DILEMMAS

Psycho-social care of cancer patients is full of ethical dilemmas for the professionals, including communication issues like to tell or not to tell or to tell relatives or patients !! This invariably leads to collusion, a conspiracy of silence, and an atmosphere of mistrust in the family. Another issue in a financially impoverished family is to decide whether to spend hard earned finances on family or invest on expensive cancer care. Decision making and making choices can be very stressful for all. The role of traditional healers and complementary and alternative medicine providers, qualified, and unqualified is another issue in a country where such traditional methods are relatively inexpensive, understandable by the public and popular.[32] Ethical dilemmas are also common in dealing with requests for euthanasia[33] caring for the dying person, answering questions about death and dying, and about how to provide spiritual care?[34,35] The psychiatry of palliative medicine looks at many such important aspects.[36]

CONCLUSIONS

In conclusion, psychiatric oncology has made numerous advances in the understanding of psychiatric disturbances, and care of cancer patients. Recent meta analysis[37] and guidelines for psychopharmacology[38] highlight the advances in this field. The role of psychological treatments in the management of psychological problems is not doubted by physicians and surgeons. However, oncologists are skeptical about the recent claims that psychological factors and stress have a significant role in causation of cancer or relapses. Research on psychiatric oncology is gradually overcoming the methodological stringencies and hopefully the coming years would present results acceptable to the scientific community. New studies in psycho oncology have focused on the relationship between psychosocial factors and cancer, detection of distress and psychiatric morbidity, intervention, and coping methods used by survivors. Predictors of treatment response among cancer patients to psychiatric intervention will be of clinical significance.[39] Research in psycho oncology is an exciting area despite numerous challenges and the principles are as applicable for Consultation Liaison Psychiatry.[40]