Management of psychiatric disorders in patients with cancer

Psychiatric disorders are seen at an increasing rate in those diagnosed with cancer. The most common psychiatric disorders that are seen are delirium, depression, adjustment disorders, anxiety, sexual dysfunctions, and sleep disorders, which overall affect 30%–40% of people diagnosed with cancer. The incidence of psychiatric disorders among those in an advanced phase of cancer illness is higher. However, psychiatric disorders are underdiagnosed and under-treated and affect quality of life (QoL) of a person with cancer. The advancement in psychopharmacology, availability of newer and better tolerated drugs with lesser side effect profile has been a boon in the field of clinical psycho-oncology. There has been growing evidence for the use of nonpharmacological interventions in reducing distress and treating psychiatric disorders. Hence, psycho-oncology is becoming a specialized novel area, integrating psychiatry, psychology into the care of oncology.

The definition and various aspects of psycho-oncology have been covered in different chapters of a recent book on psycho-oncology.[1] Here, we focus on the most common psychiatric disorders, their assessment, and their treatment focusing on the pharmacological and nonpharmacological aspects. We have looked at literature and guidelines from various countries and made a comprehensive summary of all, which can start as the beginning point for formal guidelines for the Indian setting. These guidelines will enable standard care and uniformity in procedures and practices across hospitals in the country. This is in the hope of also intriguing clinicians and researchers to focus on specific areas of psycho-oncology and develop the guidelines further.

In the first part of the chapter, we cover some basics and key areas of pharmacological management in psycho-oncology. The general principles of pharmacological management in Box 1, interaction of anticancer drugs (ACD) and psychotropics in Table 1, anticancer medications induced psychiatric issues in Table 2 and a list of anticancer drugs with no known interactions with psychotropics in Box 2.

Box 1.

General principles of pharmacological management in psycho-oncology

For all drugs – start low and go slow, i.e., to start from the lowest possible dose and uptitrate gradually based on need and tolerability. To stop at the minimum effective dosage for an individual

Look for drug interactions and adverse effect profile of the drug before initiating pharmacotherapy. Due consideration should be given to pharmacokinetic and pharmacodynamic properties of the drug, as people with cancer can have deranged metabolic parameters

Not much is known about interaction of chemotherapy, radiation therapy, and newer modalities of cancer treatments on the pharmacological properties of psychotropics. However, the clinician should take a very careful judgment about the medication that might suit the profile of the patient best

The utility of nonpharmacological interventions should be emphasized and should begin as a mainstay modality in mild and mild–moderate psychiatric disorders

Routine information of use of any ayurvedic, homeopathic, or other medication should be looked at as psychotropics can have interactions with these medications

Table 1.

Drug interactions of psychotropics and anticancer medications

Anticancer drug	Psychotropic	Interaction	Mechanism of interaction	Recommendation
Carmustine Dacarbazine Nilutamide Tamoxifen Gemcitabine	Naltrexone	Hepatotoxicity	Unknown	Avoid concurrent use. Periodic monitoring of liver function and watching for signs of hepatotoxicity
ACDs with* in foot notes	Clozapine	Myelosuppression	Additive synergistic effect	Clozapine should be avoided when person is on treatment with ACDs
Cyclophosphamide Ifosfamide Doxorubicin Etoposide Dexamethasone Methylprednisolone Prednisolone Prednisone Vinblastine Vincristine Vinorelbine Toremifene Tamoxifen	Fluvoxamine	Increased dose of ACDs	CYP3A4 inhibition by fluvoxamine	Prescribe with caution, reduce dosage od AD/switch to a safer AD
Cyclophosphamide Ifosfamide Sorafenib	Bupropion	Increased dose of AD	ACDs inhibit CYP2D6 which reduces clearance of bupropion	Look out for signs of bupropion toxicity like seizures, tremors, anxiety symptoms, agitation, insomnia, or neuropsychiatric symptoms
Imatinib	Anti-Alzheimer’s agents** Antipsychotics** Hypnotics and anxiolytics** Selective serotonin-reuptake inhibitors** Tricyclic antidepressants** Other antidepressants** Other psychotropics**	Increased doses of psychotropics	Imatinib inhibits CYP2D6 and CYP3A4	Dose adjustments when Imatinib is introduced or taken out from chemotherapy.
Imatinib	Bromocriptine, fluoxetine, sertraline	Increased concentrations of both ACDs and AD	ACD and AD Inhibit of cytochrome P450	To look out for serious adverse effects such as edema, hematologic toxicity, and immunosuppression
Methotrexate	Haloperidol	Increased risk of haloperidol-induced photosensitivity	Unknown	Patients were monitored for photosensitivity reactions. Also advised to avoid exposure to sunlight or bright lights
Tamoxifen	Antidepressants (Tricyclic AD >SSRI) Antipsychotics (phenothiazines, butyrophenones)	Increased risk of drug-induced QT prolongation and torsades de pointes	Additive effects of blocking potassium channels	Measurements of QT intervals and Watch for symptoms of torsades de pointes (syncopal attack, palpitations, and dizziness). In case of QT prolongation, reduce dosage/stop the offending agent
Tamoxifen	SSRIs - citalopram, fluoxetine, paroxetine, sertraline	Increased plasma level of tamoxifen	Inhibition of CYP2D6-mediated metabolism of tamoxifen to endoxifen	Dose adjustments of SSRI when tamoxifen is introduced or taken out from chemotherapy

ACDs with * – Cyclophosphamide; dacarbazine; mechlorethamine; melphalan; procarbazine; temozolomide; rituximab; trastuzumab; bleomycin; doxorubicin; epirubicin; etoposide; irinotecan; topotecan; carboplatin; cisplatin; oxaliplatin; docetaxel paclitaxel; vinblastine; vincristine; vinorelbine; cytarabine; fluorouracil; gemcitabine; methotrexate; pemetrexed; **Anti-Alzheimer’s agents (donepezil; galantamine); **Antipsychotics (aripiprazole; chlorpromazine; fluphenazine; haloperidol; olanzapine; prochlorperazine; quetiapine; risperidone; trifluoperazine; ziprasidone); **Hypnotics and anxiolytics (alprazolam; chlordiazepoxide; clonazepam; diazepam; flurazepam; midazolam; promethazine; propanolol; zolpidem); **Selective serotonin-reuptake inhibitors (citalopram; paroxetine); **Tricyclic antidepressants (amitriptyline; clomipramine; doxepin; imipramine; nortriptyline); **Other antidepressants (mirtazapine; venlafaxine); **Other psychotropics (atomoxetine). ACD – Anticancer drug; AD – Antidepressant; SSRIs – Selective serotonin reuptake inhibitor; QT – Not applicable

Table 2.

Anticancer medication induces psychiatric disorders and their management

ACD	Psychiatric disorders	Management options
Asparaginase Procarbazine Tamoxifen Vincristine Vinblastine	Depressive symptoms	Establish a temporal correlation between the starting of ACD and onset of psychiatric symptoms
Look for improvement in symptoms during drug-free periods Asparaginase Arabinoside Bleomycin Carmustine Cisplatin Cytosine Ifosfamide Methotrexate Procarbazine Vincristine Vinblastine 5-fluorouracil	Delirium	To work in liaison with the primary treating team and inform psychiatric diagnosis and need to adjust/switch/discontinue ACD after weighing out the potential benefits and risks A brief and comprehensive medical and psychiatric assessment (to look out for risk factors) Aim to reduce the modifiable risk factors Psychoeducate and reassure the patient. Help manage minor symptoms with nonpharmacological approaches Psychotropic agents can be initiated in those with moderate-to-severe symptoms. To keep in mind, drug interactions, adverse effects profile, and regular monitoring as required The patient and family members must be psychoeducated regarding the etiology of psychiatric symptoms and way forward plan
Cisplatin Cytarabine Fludarabine Methotrexate 5-Fluorouracil	“Chemobrain” - difficulty in attention, executive functions, short-term memory, recall deficits, and multitasking
Calcineurin inhibitors (ciclosporin, tacrolimus)	Neurotoxicity
Interferons and interleukins	Depression, anxiety, psychosis, suicidal ideation, hypomanic symptoms, and cognitive impairment
Isotretinoin	Depression, suicidal ideation, and psychosis
Antihistamines (1st-generation H1 antagonists >newer antihistamine agents)	Sedation, delirium, cognitive impairment, agitation, and psychosis
Corticosteroids (dose-dependent adverse effects)	Emotional lability, anxiety, irritability, insomnia, cognitive impairments, mood disorders, delirium, reversible dementia, and psychotic disorders Acute use of corticosteroids – hypomania/mania Chronic use of steroids – depression, dependence

ACD – Anticancer drug

Box 2.

Anticancer drugs that do not have any known interactions with psychotropics

Alitretinoin

Anastrozole

Capecitabine

Exemestane

Fulvestrant

Goserelin

Letrozole

Leucovorin

Leuprolide

Lomustine

Mesna

Mitoxantrone

At this stage, we have understood some pharmacological aspects of psycho-oncology. Now, we will look at the nuances in the assessment and treatment of individual psychiatric disorders with respect to psycho-oncology.

DEPRESSIVE DISORDERS

Introduction

In cancer patients, depression is one of the most commonly diagnosed psychiatric disorders.[2] The incidence of major depressive disorder can range from 15% to 40%. Depressive disorders can be on a spectrum and can include major depressive disorders, persistent depressive disorders, dysthymia, adjustment disorder, and demoralization syndrome. Diagnostic guidelines such as ICD-10 or DSM-V can be used to make a diagnosis. However, the clinician should be aware that there is overlap in the biological symptoms of depression and symptoms of cancer or adverse effects of the treatment. It is crucial and important to delineate the symptoms and make a correct diagnosis of depression. There are various approaches described below:

• Inclusive approach – To include all the symptoms of depression, even if some may be attributable to cancer

• Substitute approach – Somatic symptoms replaced by cognitive and affective symptoms (Endicott’s criteria)[3]

• Alternative approach – To add some new affective symptoms to the original criteria (Akechi’s criteria)[4]

• Exclusive approach – Somatic symptoms are excluded in entirety, and only affective symptoms are considered to make a diagnosis (Cavanaugh’s criteria).[5]

For more details on the various approaches, readers are encouraged to read the references mentioned. Depressive disorders when identified and treated improve the QoL and decision-making capacity.

Assessment

A detailed assessment must be done with regard to a good history on independent symptoms and current treatment, past history – psychiatric and medical, detail family history, and also substance use history.

Scales that help understand the intensity and severity are:

• Brief symptoms inventory

• Hospital anxiety and depression scale.

These are widely used to assess psychological distress. These are specifically designed to detect depressive symptoms in medically ill patients.

Other scales are as given below:

• Center for Epidemiological Studies – Depression

• Beck depression inventory.

They have acceptable sensitivity and specificity in cancer patients.

Management

Treatment of depression in cancer patients with depression should also involve their families. Holistic care encompassed the following components of providing adequate information, support in making appropriate decisions, informed consent for psychotherapy and other management when necessary.All of this should be done while being sensitive and respectful to the patients familial, religious, cultural and ethnic background as well. The liaison between the cancer care physicians and mental health team is important for a well-coordinated care and good outcome of treatment. A list of contributing factors for depression are given in Box 3. NICE guidelines have given a flowchart for step-wise care for depression in people with cancer [Figure 1]. The management of mild, moderate, and severe depression is discussed in the previous IPS Guidelines on Depression and should be referred to for the treatment of depression in cancer as well.

Box 3.

Contributors for depression

Vitamin B12 deficiency

Hypothyroidism

Folate deficiency

Anemia – Iron deficiency

Electrolyte imbalance

Figure 1.

Stepped care model for delivery of care[6] (adapted with permission)

Pharmacological management

Psychopharmacological studies show evidence that antidepressants are more effective than placebo in both cancer patients with major depressive disorder or depressive symptoms and distress related to cancer.[7,8,9] However, considering poor health status and adverse effects, the utility of ADs should be restricted to those with moderate-to-severe depressive episode. Those with mild depression should be started on ADs if psychosocial intervention does not produce desired change in mood or activity.

Guidelines for the use of antidepressants in cancer patients[1]

• Medications are initiated at low dose and titrated very gradually to achieve an optimum individualized response (initial low doses have shown to reduce initial side effects and are better tolerated, particularly in patients with fragile physical conditions)

• Patients need to be informed about the time taken for titration, time after which medication has effects (latency period), and most common/serious adverse effects and monitoring if required. This helps in reducing medication stoppage, especially if patients are receiving other medications

• Treat the patient for a minimum period of 4–6 months to avoid relapses or recurrence of depression postremission

• Regular monitoring of vitals and blood parameters and check on the concomitant use of medications for cancer (e.g., steroids, antiemetics, antibiotics, antiestrogen, and chemotherapy agents)

• The process of stopping ADs should be a slow process and the clinician should keep in mind to reduce 25-50% of the dose once in 2-4 weeks. This reduces the risk of possible withdrawal symptoms that can be distressing for a patient. Sometimes, withdrawal may be mistaken for relapse of depression or worsening of symptoms of cancer

• Psychoeducation and reassurance are extremely important in oncology settings.

Most of the evidence comes from case studies or open trials, and as per current research and guidelines practiced, selective serotonin reuptake inhibitors (SSRIs) are the first line of treatment as they have a lesser side effect profile.

1. SSRIs – The most commonly used medications including citalopram, escitalopram, and sertraline are useful to treat depression in patients with cancer and also are found to be beneficial for anxiety and hot flashes. Duloxetine, an antidepressant along with treating depression, also has benefits in chronic musculoskeletal pain, chemotherapy-induced peripheral neuropathy, and neuropathic pain

2. Serotonin norepinephrine reuptake inhibitors (SNRIs) – Venlafaxine and desvenlafaxine are used to treat major depression, anxiety, and neuropathic pain

3. Tricyclic antidepressants (TCAs) – For neuropathic pain, TCAs have to be used judiciously as they can have severe and intolerable side effects such as constipation, dry mouth, and sedation

4. Noradrenergic and specific serotonergic antidepressants (NaSSAs) – Mirtazapine can be used to treat sleep disturbances and nausea; the metabolic adverse effects have to be kept in mind.

Nonpharmacological management

The type of therapeutic intervention must be given due to thought considering symptoms and factors that contribute to depression. Recently diagnosed patients with cancer with mild-to-moderate depression may benefit from psychoeducation, cognitive-behavioral therapy (CBT), relaxation strategies, and problem-solving approaches.[10] Patients who have more advanced disease may benefit from supportive-expressive psychotherapy that focuses on processing fears associated with death and other existential concerns.[10] Recent development of manualized targeted psychotherapies for those with advanced illness includes Meaning-Centered Group Therapy,[11] Dignity Therapy,[12] Mindfulness-Based Meditation Therapy,[13] and a brief supportive-expressive intervention referred to as CALM[14] (Managing Cancer and Living Meaningfully). Table 3 gives a list of psychotherapeutic interventions.

Table 3.

Description of psychological interventions

Term	Description
Counseling	Generic term used to refer to supportive psychosocial care provided by a qualified professional
Psychoeducation	A process of a professional providing information to create awareness, increase knowledge and understanding about a certain condition, in turn, reduce the uncertainty, and improve a person’s mental health
Relaxation training	Teaching skills for releasing physical or mental tension using meditative activities, progressive muscle relaxation exercises, or use of guided mental imagery
Problem-solving therapy	Focuses on generating, applying, and evaluating solutions to identified problems
Cognitive-behavioral therapy	Focuses on identifying, challenging, and changing distorted thoughts and maladaptive beliefs and behaviors, which then reduce negative emotions and lead to positive psychological adjustment
Interpersonal therapy	Focuses on problems within interpersonal domains such as grief, role transitions, role dispute or interpersonal deficits. Therapy aims to reduce distress and promote positive psychological adjustment
Supportive-expressive therapy	A subjective experience is processed with the help of the therapist in a positive therapeutic relation to enable psychological adjustment (e.g., meaning-centered therapy, dignity therapy, and CALM)

CALM – Cancer and living meaningfully

Demoralization

The term demoralization was first described by Frank Jerome in 1970s. Demoralization is considered as a normal reaction to a particular situation. Usually, the situation is a medical illness, such as cancer, treatment for their condition, etc. It can coexist with other psychiatric disorders such as depression, anxiety, and adjustment disorder. Table 4[15] enumerates the ways to distinguish demoralization from other psychiatric disorders.

Table 4.

Differentiating points for various psychiatric conditions seen in cancer[15]

	Depression	Demoralization	Adjustment disorder	Anxiety disorders
Duration of symptoms (minimum)	2 weeks	2 weeks	Usually have a stressful event/change and symptoms start <1 month of change	Symptoms which last for most days of a week for a few weeks
Stressor	+/−	+	+	+/−
Affective symptoms	Sad/Depressed +/− anxiety	Distress secondary to existential crisis, hopelessness, sense of loss of meaning, and purpose in life	Excessive worry, anxiety, depressive symptoms	Anxious affect
Cognitions	Helplessness, hopelessness, worthlessness	Pessimism, helplessness, sense of feeling trapped, looking at self as a failure or as lacking a worthy future, subjective sense of self-incompetence, may extend to hopelessness	Sense of low confidence, difficulty in coping	Fear of negative consequences, usually related to the future
Arousal symptoms	Present only when associated with anxiety symptoms	None	Can be present when exposed to stressor	Usually, present
Motivation, hedonic pleasure	Amotivation Anhedonia	Motivation present, but dilemma in direction of action In severe cases, can have amotivation Hedonic pleasure preserved	Motivation present, but dilemma in direction of action Hedonic pleasure preserved	Motivation preserved Hedonic pleasure preserved
Sleep	Insomnia, usually early morning awakening	Usually sleep intact	Can have insomnia	Can have insomnia
Pervasivity	Pervasive	Nonpervasive	Get better with removal of stressor or change in environment	Can be pervasive to situation specific

ANXIETY DISORDERS

Introduction

Among those diagnosed with cancer, anxiety is commonly seen as a response to threat or fear of uncertainty, suffering, and mortality. In cancer centers, anxiety to a mild degree is seen in almost everyone with fluctuating levels, and anxiety is highest at times of evaluation, surgery, and other treatment/interventions. However, anxiety at a disorder level[16] is seen in approximately 35% of cancer patients; this is higher than what is seen in general population. Anxiety can result in effective medical decision-making ability, can worsen existing medical symptoms, and can interfere with cancer care.[17] Anxiety and depression are seen to coexist in a lot of people diagnosed with cancer. Anxiety when assessed is associated with poorer QoL. Anxiety can be mild to severe in intensity. Among anxiety spectrum disorders, we can find generalized anxiety, social anxiety, specific phobias, obsessive–compulsive disorder, acute stress reaction, and posttraumatic stress disorder. The clinical symptoms and diagnosis usually made on the criteria as per the ICD-10 or DSM-V. The assessment scales used to assess are the same as those that are used in depressive disorders.

It is important to note less-discussed diagnostic criteria, mixed anxiety depression, where the symptoms do not complete anxiety/depressive disorder. This can be managed on the lines of mild depression/mild anxiety disorder.

Management

In mild anxiety disorders, the first line of management is psychosocial management; in cases with poor response to treatment, pharmacological management should be considered. In moderate-to-severe cases, pharmacological management is combined with psychosocial treatment for adequate treatment.

Pharmacological management

The guidelines to start and treat with SSRIs in anxiety are like those in depression. SSRIs, benzodiazepines and nonbenzodiazepine anxiolytics can be used to treat anxiety.[17] Benzodiazepine and nonbenzodiazepine analogs can be used to treat anxiety acutely. They should be tapered and stopped at the earliest possible time. Clinicians should be aware of the potential of dependence and complications in those with alcohol abuse/dependence; paradoxical reactions in the elderly; and disturbance in concentration, drowsiness, and possibility of falls in the frail and elderly patients. The dosage should be given at a minimum and titrated based on improvements, tolerability, and adverse effect profile.

SSRIs that are used in cancer patients are citalopram, escitalopram, and sertraline, while SNRIs, i.e., venlafaxine and desvenlafaxine, can be used to treat anxiety as they have less interaction with other drugs. Clinicians should try and avoid fluoxetine, fluvoxamine, and paroxetine as they can alter the levels of chemotherapeutic, hormonal therapy and can worsen nausea in cancer patients. Antidepressants can be used for longer duration as required.

Other anxiolytics are buspirone, mirtazapine, and atypical antipsychotics (APs) at low doses. Buspirone is an anxiolytic with no addictive potential but has 2–3 weeks for onset of action. Mirtazapine is a good drug of choice when anxiety is associated with insomnia and anorexia as sedation and possible weight gain, which are common adverse effects, are seen to be beneficial here. Low-dose atypical AP, e.g., olanzapine/quetiapine, and anticonvulsants, such as gabapentin, are also used in our routine clinical practice to treat symptoms of anxiety. The drugs with off-label use are not FDA approved and have not been adequately studied in patients with cancer.

Nonpharmacological management

A nonpharmacological approach to address anxiety and related symptoms has shown to be effective. The various intervention techniques include psychoeducation, CBT, problem-solving therapy, mindfulness, and supportive-expressive group therapy.[18]

Conventionally, CBT focuses on restructuring cognitive distortions and negative automatic thoughts and changing intermediate and core beliefs to help the person break the vicious thought process of anxiety. Basic behavioral strategies such as gradual exposure and systematic desensitization can help reduce avoidance and fear in anxiety-provoking situations.[19] The above-mentioned interventions would not be applicable to people in advanced or terminal stages of their illness where existential concerns, increased disability, reduced functioning capacity; perceived burden posed to family caregivers; physical symptoms; and adverse treatment effects are the issues addressed in those receiving palliative care.[20]

Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) is an amalgamation of cognitive and behavioral strategies; it involves various processes such as acceptance, commitment, mindfulness, and behavior change, to enable the process of psychological flexibility.[21] The six processes of ACT are being in contact with the present moment, defusion, self as a context, acceptance, values and committed action.[22] ACT can be used in individual and group settings. It is shown to have moderate-to-large improvements in cancer-specific QoL outcomes.[23]

Mindfulness-based cognitive therapy

Mindfulness -based cognitive therapy aims to help a person be mindful, nonjudgmental, and acceptant of their thoughts, emotions, experiences, and bodily sensations. The skills of mindfulness learnt help to achieve a state of self-acceptance, decrease the focus on thoughts and to look at them as transient events occurring in the mind and not as the accurate reflections of reality.[24]

DELIRIUM

Introduction

Among neuropsychiatric disorders, delirium is most commonly associated with cancer. Delirium is associated with high rates of mortality, morbidity, increased burden on caregivers, increased duration of hospital stay, and health-care cost.[25,26] Delirium is usually undiagnosed, untreated, or undertreated. Delirium is seen in 20%–30% of people diagnosed with cancer, and the incidence is 85% in those with terminal illness.[27] It can be caused due to various treatable and reversible causes and can also be caused due to irreversible causes, as in terminal delirium. Those at higher risk of developing delirium are given in Box 4, The medications implicated in causing delirium are outlined in Box 5 and reversible causes of delirium are listed in Box 6, Risk factors for delirium in Box 7, clinical signs of delirium in Box 8 and subtypes of delirium in Box 9.[1]

Box 4.

Those at higher risk of developing depression

Inadequate pain control

Life stress or loss

Past history of depression

Level of physical impairment

Patients with lung, gastric, oropharyngeal, and gastric cancer

Substance use

Brain tumor, vascular vulnerability, parkinsonism, Lewy body disease

Family history of depression

Poor coping skills

Box 5.

Medications that can cause depression

Hormonal agents such as aromatase inhibitors, gonadotropin-releasing hormone analogs, and selective estrogen receptor modulators

Chemotherapeutic agents - prednisone, dexamethasone, procarbazine, asparaginase, tamoxifen, vincristine, vinblastine, interferon, and interleukin 2

Opioids

Amphotericin B

Statins

Varenicline

Box 6.

Reversible causes of delirium

Cancer disease related

Brain tumor and/or metastatic illness

Paraneoplastic syndrome

Ectopic hormone-producing tumor (ACTH, ADH, insulin-like, parathyroid hormone)

Cancer treatment

Chemotherapy drugs

Corticosteroids

Radiation therapy – brain

Cancer pain drugs

Opioids

Antidepressants

Psychostimulants

Infection

Other drugs

Anticholinergics (Benadryl, tricyclic antidepressants)

Anti-Parkinson drugs (levodopa)

Centrally acting antihypertensives (methyldopa, reserpine)

Corticosteroids

H2 blockers (cimetidine)

Narcotics (meperidine)

Sedative hypnotics (benzodiazepines)

Metabolic disturbance

Hypoxia

Hypercapnia

Increased or reduced blood sugar levels

Vitamin deficiencies (B12, folate)

Electrolyte imbalance (Na, K, Ca)

Anemia

Dehydration

Impaired nutritional status

Hepatic or renal dysfunction

Environmental

Hospitalization

Use of physical restraints

Catheterization

H2 – Histamine-2; ACTH – Adrenocorticotrophic hormone; ADH – Anti-diuretic hormone

Box 7.

Risk factors of delirium

Age of ≥65 years

Past history of delirium, dementia, and/or cognitive impairment

Preexisting low physical/cognitive activity levels

Impaired vision/hearing

Dehydration, malnutrition

Alcohol abuse/use of psychoactive substances

Advanced phase of cancer illness

Comorbid medical conditions

Box 8.

Clinical signs in delirium

Altered levels of consciousness (alertness or arousal), even amounting to disorientation

Disturbances in attention

Abrupt onset and rapidly fluctuating clinical course

Cognitive disturbances characterized by difficulties in higher mental functioning like apraxia, memory impairment, executive dysfunction, agnosia, visuospatial dysfunction, and language disturbances

Psychomotor activity – Increased or decreased

Disturbance of sleep cycle, worsening of symptoms with sundowning

Mood symptoms - dysphoria, mood lability, euphoria, agitation

Perceptual disturbances (hallucinations or illusions) or delusions

Disorganization of thought

Speech can be incoherent

Neurologic findings - asterixis, myoclonus, tremor, frontal release signs, changes in muscle tone

Box 9.

Subtypes of delirium

Hyperactive delirium

Hypoactive delirium

Mixed delirium

Clinical signs

Delirium is characterized by an abrupt onset of disturbances of consciousness (i.e., arousal), attention, cognition, and perception that fluctuate over the course of the day.[25,27]

Subtypes of delirium

There are three types of delirium based on clinical signs, hypoactive subtype, hyperactive subtype, and mixed type of delirium. Hypoactive delirium is characterized by withdrawn behavior, quietened appearance, drowsiness, reduced arousability and low to absent voluntary reporting of experienced distress. Hyperactive delirium characterized by restlessness, agitation, and aggressiveness is more easily recognizable. Mixed delirium is characterized with alterative periods of hyper- and hypo-active delirium. Levels of distress are almost similar in those with hypoactive/hyperactive delirium, and mortality rates are higher in hypoactive delirium as compared to hyperactive delirium.

Assessment

The assessment should involve focused history of symptoms of delirium, medications, and treatment history; assess systemic comorbidities, signs of infection, and all reversible causes of delirium; and use tools to assess delirium. There are various tools to assess delirium, including:

• Memorial delirium assessment scale[28]

• Delirium rating scale-revised 98[29]

• Confusion assessment method.[30]

These scales are validated and can be used in cancer care centers.

After assessment and understanding the severity of delirium, we should assess for the causes of delirium as mentioned in Box 4.

Management

After screening and assessment of delirium, any treatable causes must be addressed, and periodically, delirium should be re-assessed to observe any improvements in the delirious state. The aim of treating delirium is to see a person alert, conscious, calm, comfortable, intact cognitions, not psychotic, pain-free, and coherently communicating.[27]

Pharmacological management

As a first step, look for the current ongoing medications, and stop any drug with potential to precipitate or worsen delirium. The management of delirium is mentioned briefly here; we recommend the readers refer to IPS Guidelines on Management of Delirium and adopt the same here.

Pharmacological treatment of delirium

Antipsychotics

Haloperidol is the gold standard drug currently used to manage delirium. Haloperidol at doses of 0.5–1 mg can be given intravenous (IV) or intramuscular (IM) route hourly with baseline and regular ECG monitoring for risk of QTc prolongation. Haloperidol should be used with great caution in those sensitive to EPS and those with preexisting dementia. Low-dose chlorpromazine is an acceptable alternative. Second-generation APs – olanzapine, risperidone, and quetiapine – can be tried in hyperactive delirium and aripiprazole in hypoactive delirium. The evidence for the use of second-generation APs is limited.

Benzodiazepines

Benzodiazepines can be used in patients with agitation and distress. Midazolam and lorazepam can be used as subcutaneous/IV/IM routes. It should be used with caution in the elderly and may cause falls, increased sedation, and respiratory depression. They can also cause paradoxical worsening of agitation. Should start at the lowest dose, around 0.5 mg/h or 1 mg can be repeated every 2 h until the patient is sedated.

Psychostimulants

The role of Psychostimulants in delirium has been less studied. There is one open-label study showed good efficacy of using modafinil with antipsychotics in hypoactive delirium. There are case reports to give evidence for use of methylphenidate with antipsychotics in hypoactive delirium as well. Modafinil and methylphenidate have shown some positive efficacy in terminally ill patients. However, due consideration should be given to the possibility of drug-induced exacerbation of psychotic symptoms or precipitation of agitation.

Cholinesterase inhibitors

Rivastigmine and donepezil have been theoretically implicated in correcting the cholinergic imbalance seen in delirium. However, they have not shown evidence to be beneficial in delirium. There have not been any studies done specifically on cancer. Hence, use of these is not recommended in cancer patients with delirium.

There have been various studies looking at preventing delirium in acute care setting, specifically in the elderly. Various pharmacological agents such as APs, melatonin, dexmedetomidine, rivastigmine, and donepezil have been tried, but the evidence is sparse and requires more robust clinical trials.

Terminal delirium[31]

The role of sedation in terminal delirium is debatable. However, in some cases, palliative sedation may be required. Physicians should make this decision in discussion with the family, and there should be documented informed consent.

• First line: Midazolam and haloperidol as a combination –Titrate midazolam gradually to maximum dose of 20 mg/24 h, very rarely up to 25–30 mg/24 h evaluating the level of agitation. Low doses of haloperidol can be injected

• If midazolam is ineffective, IV infusion of propofol, phenobarbitone, or pentobarbitone can be used. Dose is gradually titrated up until desired symptom control is achieved.

Nonpharmacological management

The role of nonpharmacological interventions is limited and is used as a supportive intervention to the primary medical management. The key aspects of identifying the contributing and comorbid conditions and treating them are primary. Nonpharmacological and supportive therapies do not have direct effect on mortality or QoL. Nonpharmacological interventions can help in a faster recovery in delirium.[32]

Nonpharmacological strategies including psychoeducational, cognitive retraining help reduce distress in caregivers. Although they directly are not effective in controlling delirium symptoms, they do not pose any harm or risk.

Richeimer explains two levels of intervention – cognitive interventions and emotional interventions,[33] which the caregivers can be trained to do regularly. The cognitive interventions aim to restore cognitive functioning, while the emotional intervention aims to cope with overwhelming emotions.

Tables 5 and 6 illustrate the application of the two psychological interventions in delirium and their components.

Table 5.

Cognitive interventions in delirium

Intervention	Method	Explanation	Example
Clarify	Correct misperceptions	It targets the tendency of the patient to misperceive his/her environment. Orientation to place, date, day, time is useful	This room is not a laboratory but an ICU. All people here are trying to help you
Verify	Confirm accurate perceptions	Verification and validations compensate for the decreased ability to differentiate between real and not real	“Yes, there is a lot of strange equipment around you, but of all which is necessary to treat you”
Explain	Provide information about illness, treatment, and current environment	Explanation compensates for patients’ decreased ability to understand recent events, circumstances, and environment	‘The reason you are seeing things is because your kidneys are not working well. It is common to have hallucination with such problems”
Repeat	Useful information frequently repeated	Patients with delirium have impaired memory. Frequent repetition of all interventions is important	Good evening. You may remember me from this morning. I’m Dr. A, and it is 7 pm, Monday, July 20th

ICU – Intensive care unit

Table 6.

Emotional interventions in delirium

Intervention	Method	Explanation	Examples
Acknowledge feelings	Confirm the existence and reasonableness of patient’s feelings	Delirious patients often are in life-threatening situation and receiving intensive medical treatment. They are likely to fear not only death but also pain, abandonment, incapacity, and insanity	I understand that you are feeling frightened. This is a pretty upsetting place. Other patients feel scared at times too
Provide familiarity	Well-known people and objects to be provided in their environment	Paucity of familiar sights and sounds intensifies the strangeness and fearfulness of the environment	Same room, same medical team, favorite TV shows
Alleviate isolation	Allow for sharing of emotional burden	Emotional burden when shared relieves distress and isolation.	“I can imagine that you fear you might die here”
Fostering a sense of control	Allow patients control of the environment, body, treatment whenever possible	For some, complete dependency on caregivers may be anxiety-provoking. Regaining as much control as possible is important	“Here is the remote to adjust your bed, please use it”
Balance of hope and realism	Provide realistic information with hope and optimism	For patients who are aware of the seriousness of illness, it is helpful to acknowledge it. To verify their perception of the situation. Denial of this can make them lost trust in their medial team	“Yes, your illness is serious, and operation does come with it risks, but doctors are very confident and hopeful of a positive outcome”

Delirium in patients of advanced stages of cancer can contribute to high distress levels for family members. One crucial component that must be emphasized within the multidisciplinary intervention is psychoeducation of family members/caregivers and improved their knowledge, emotional state, and response toward the delirious patient. Caregivers who are educated about delirium are seen to be more confident and able to make good decisions.

CANCER-RELATED FATIGUE

Introduction

NCCN guidelines define cancer-related fatigue (CRF) as a “persistent, distressing, subjective feeling of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment” and when severe does not improve with rest (Fatigue, 2018). CRF is also disproportionate to the activity levels and interferes with routine activities. CRF is seen in 40%–100% of people with cancer.[34] CRF can be associated at any stage of illness (at diagnosis, during treatment, or end-of-life care) and can even persist for prolonged durations sometimes years posttreatment. CRF impacts the QoL, and its effect is pervasive and profound. This reduces the capacity to work and to participate in activities (social/leisure) and may interfere with sustaining relationships that are meaningful.[34] The mechanism of CRF remains elusive to date; however, the implication of cytokines, interleukin, tryptophan degradation, and other physiological and biochemical mechanisms has a role to play.[35]

Assessment

The most important thing to understand in CRF is that it is a subjective experience, usually underdiagnosed and undertreated.[36] Hence, we stress the need for screening and evaluation of CRF and re-evaluation at regular intervals to understand its burden on QoL and cancer care. MD Anderson symptom Inventory can be used to score the severity of CRF.[37] Similarly, other scales that can be used are 10-point numeric rating scale for fatigue[38] and brief fatigue inventory.[39]

The first and foremost step is to take a detailed history and focus on the symptom of fatigue and its associated symptoms. A comprehensive and focused diagnostic assessment should be done aiming at identifying contributing and comorbid conditions.[35] In the evaluation of fatigue, a history should assess the onset, course, duration, exacerbating and alleviating factors. Along-side that, the assessment should also include looking for emotional distress, weight gain/loss, nutritional status, sleep, activity levels, ongoing medications, substance use and comorbid conditions. A detailed physical examination focuses on signs of anemia, dehydration, edema, jaundice, and any other physical abnormalities. The brief investigation panel should include complete blood count, serum electrolytes, thyroid panel, blood and urine culture to rule out any active infections and gonadal hormones when necessary. A list of treatable causes and contributing causes of CRF is given in Table 7.

Table 7.

Enlisting the treatable causes and contributing factors for cancer-related fatigue[40]

Treatable contributing causes	Comorbid factors
Anemia	Infections
Sleep-related problems and poor sleep hygiene	Hypothyroidism
Poor nutritional status/poor oral intake	Hypogonadism
Fluid and electrolyte imbalances	Cardiac/renal/hepatic/pulmonary/neurological dysfunction
Emotional distress (anxiety/depression/other)
Low activity levels
Adverse effects of medication/other modalities of treatment
Substance use

Management

After screening and assessment of CRF, any treatable causes have to be addressed, and periodically, the CRF should be re-evaluated to note for any improvements. There has been improvement noted in cases where anemia, electrolyte imbalance, or other treatable causes have been addressed. In cases where there are no identifiable treatable causes, one should evaluate the severity of CRF and stage of disease, and for mild and mild–moderate cases, nonpharmacological management is recommended; for moderate-to-severe and severe cases of CRF, a combination of pharmacological and nonpharmacological management is recommended.

Pharmacological management

We should be aware that there are not enough clinical trials or consensuses on the applicability of pharmacological management of CRF. Clinicians and researchers have tried to look at the utility of psychostimulants, antidepressants, corticosteroids, and nutraceutical agents in the treatment of CRF. Here, we describe a summary of the existing guidelines.

Psychostimulants

The class of psychostimulants includes amphetamines such as methylphenidate, dexamphetamine, and modafinil. Methylphenidate has shown to have some efficacy over placebo in clinical trials. Methylphenidate can be used in cases where there is no other identifiable cause for fatigue. It can be used in treatment, posttreatment, and end-of-life care.[40,41] Dexamphetamine in clinical trials so far has not shown any positive results. Modafinil, a nonamphetamine psychostimulant, has shown positive results in those with severe fatigue but not in those with mild-to-moderate levels of fatigue.[42] Modafinil has also shown benefits in patients with advanced disease in small trials but has not been replicated in larger trials.

Antidepressants

No antidepressant has been approved or shown to have high efficacy in targeting CRF.

Corticosteroids

Methylprednisolone and its derivative dexamethasone are noted to improve CRF in people with terminal or advanced illness and receiving end-of-life care. One study also reported improvement in fatigue, general condition, and absence/control of fluid retention.[43] A progestational agent, megestrol acetate has shown efficacy in cancer cachexia but not in cancer fatigue.[44] Physicians must give due consideration to the adverse effects and toxicity of long-term use of steroids and should restrict its use in terminally ill patients with cachexia and also in those with brain and bone metastasis with pain.

Benzodiazepines

Eszopiclone is a sedative-hypnotic which has been tried and has not shown improvement in fatigue scores.[45]

Nutraceuticals

L-carnitine supplementation at dosages of 1 g b.i.d. reduced fatigue symptoms.[46] Coenzyme Q10, Wisconsin Ginseng, Astragalus, Guarana, and mistletoe have also been under experimentation and need more evidence toward its efficacy and benefits in treating CRF.

Research is currently focused on the utility of modafinil, buspirone, American ginseng, L-carnitine, and coenzyme Q10 in CRF.[34]

Nonpharmacological management

Psychoeducation to the patients about CRF giving adequate information, symptoms, and what to expect can help them understand the condition and reduce uncertainty and anxiety associated.[47] A review looked at nonpharmacological treatment for CRF showed benefits with CBT, physical exercise, massage therapy, hypnosis, acupuncture, muscle relaxation, and psychoeducation for fatigue.[34,48] Interventions such as behavioral activation/activity scheduling that leads to gradual increase in physical activity are beneficial to their QoL. The interventions can be done at individual or group levels.

SLEEP DISORDERS

Introduction

Insomnia is reported in 25%–59% of those diagnosed with cancer.[49] Insomnia is usually associated with pain, hospitalization, prescription medication, anxiety, and fear about cancer and its treatment. Insomnia is highly correlated with varying levels of anxiety and depression.[50] Insomnia can

persist for varied durations, at times years after diagnosis/treatment. Insomnia when associated with high distress levels, predispose a person to physical and mental health issues which can result in a poor QoL. While most of the studies in this area are correlative in nature, it is generally the case that sleep disturbance can be a predictor of fatigue, has high correlation with fatigue, and is seen at higher severity in those fatigues than otherwise.[51]

Assessment

All patients with cancer have to be evaluated for disturbance in sleep and assessed if it amounts to a disorder level.

Screening

The National Institutes of Health in a review of patient-reported outcome measures[52] recommended two questions be used to screen for sleep problems:

1. Do you face problems with your sleep on average for three or more nights a week? If yes

2. Does the sleep disturbance negatively affect your daytime functioning?

If answer to both questions is Yes, go for focused assessment.

A detailed history should include details on time of going to bed and time of wakening, total sleep duration, time taken to fall asleep after getting on bed or sleep latency, duration of sleep during daytime, daytime sleepiness, intermittent wakening at night, perceived quality of sleep, beliefs around sleep and calculate sleep efficiency. Also look for comorbidities, substance use and review sleep log recorded over 2 weeks. This will complete the detailed evaluation of sleep.

Scales

• Insomnia severity index

• Edmonton symptom assessment system. Revised

• Pittsburgh sleep quality index for insomnia

• Epworth sleepiness scale for increased sleep can be used.

Pharmacological management

There are no specific guidelines or evidence-based approaches for treating sleep disorders in cancer. Nonpharmacological management is the first-line management for insomnia. Pharmacological management is used as a supplementary treatment modality to help the patient until they complete behavioral interventions or in those refractory to behavioral therapy.[53] The pharmacological management should be for short duration and should not exceed beyond 8 weeks.[54] Benzodiazepines should be used with caution as they have a risk of dependence. The approach should be lowest effective dose for shortest possible time.[53] Other drugs such as quetiapine, trazodone, and melatonin have been beneficial. However, evidence in cancer patients and information on adverse effect or drug interactions are limited.

Nonpharmacological management

The recommended first-line treatment for insomnia is nonpharmacological intervention, specifically CBT for insomnia. It incorporates cognitive and behavior-change techniques and targets attitudes, beliefs, and habits around sleep that are maladaptive.[55] Components of CBT are as follows:

• Cognitive restructuring, such as restructuring negative/distorted thoughts, beliefs, and attitudes in relation to aspects of sleep[56]

• Stimulus control and sleep restrictions are behavioral techniques to restrict the usage of bed for sexual and sleep-related activities only

• Cognitive, behavioral, visual imagery and relaxation techniques can be combined to produce benefits

• Basic sleep hygiene education: Have a fixed sleep and wake time, wind up and prepare to bed at least 90 min before sleep time, room must be dark, quiet, and comfortable with a good temperature, do not work/watching television/using a laptop in bed, expose yourself to adequate daylight during nonsleep hours, avoid day naps, do not consume coffee/tea/cigarettes 2–4 h before bedtime, restrict fluid intake 2 h before sleeping, ensure to have an exercise routine in place, and complete it 3 h before bedtime.

Psychological interventions – ranging from individual supportive psychotherapy to cognitive-behavioral techniques (biofeedback, hypnosis, and progressive muscle relaxation) – have been effective in reducing anxiety and insomnia.[57]

SEXUAL DISORDERS

Introduction

Sexual health is an important aspect when assessing holistically the QoL. It has an impact on various health components, i.e., physical, emotional well-being, and in turn affects the QoL. Sexual health is usually negatively affected in those diagnosed with cancer or in various stages of cancer treatments, including systemic chemotherapy, immunotherapy, surgery, radiotherapy, and hormonal therapy.[58] Approximately 30%–100% of cancer survivors have reported having sexual concerns.[58,59] Sexual health is intricately linked and affected by psychosocial health, mental health, past trauma (if any), religious and cultural factors.[60] Cancer survivors experience a wide range of sexual problems such as difficulty in arousal, vaginal atrophy, dryness/poor lubrication, decreased intensity or frequency of orgasms, reduced sexual desire, reduced sexual satisfaction, and dyspareunia. The sexual disorder further contributes to impaired body image and sexual–self-esteem.[61] Cancer patients are quite hesitant but expect their treating physicians to provide access to information and help them with the sexual difficulties due to cancer or its treatment.[62] Health-care professionals think that sensitive topics such as sexuality and sexual health must be brought up by the patients themselves.[63] Amid the chicken and egg situation, the necessary interventions to improve sexual health and QoL are hampered.

Assessment

A detailed history of the aspects relating to desire, arousal, orgasm, and resolution phase should be taken in detail. The onset, intensity, perceptions, cognitive distortions, and level of impairment caused by the symptoms to the patient and the partner should be evaluated independently. Furthermore, the level of communication, intimacy, and perception of self and partner in relation to sexual problems should be assessed. A complete biopsychosocial assessment will help in planning interventions for the person or couple in distress.

Management

The management of sexual disorders in cancer should take a multidisciplinary approach to improve sexual health and sexual satisfaction in cancer patients and survivors. The management should include a curated balance between medical and psychosocial approaches which are individualized to the person.[64] The earlier the intervention, even preventive strategies can be more effective than when initiated when the sexual disorder becomes established or distressing.

The following are the interventions suggested by Cancer Care Ontario and American Society of Clinical Oncology, summarized here as per disorder.[65]

1. Assessment – The health professional must bring up the discussion on sexual functioning and issues if any

2. Body image – Psychosocial counseling – individual or with the partner (if patient consents for partner to be involved)

3. Hypoactive sexual desire – In women, Flibanserin can be used in postmenopausal women. However, the evidence in this area is bleak. It should be as per judgment of the clinician

4. Vasomotor symptoms in postmenopausal women – If the patient does not have hormone-sensitive cancer, hormone replacement therapy (HRT) can be given. If the patient is unwilling to start HRT, fluoxetine, paroxetine, venlafaxine, gabapentin or clonidine can be tried. Paroxetine and fluoxetine are better avoided in women with hormone-sensitive tumors. Adverse effects should be considered before initiating medications

5. Vaginal dryness of pain – To start with lubricants or vaginal moisturizers, if there is no effective improvement, low-dose estrogen gels can be tried. For persistent introital pain, lidocaine gel can be tried. If there is no improvement further, selective estrogen receptor modulator ospemifene can be tried for postmenopausal women who do not have a present or past history of breast cancer. For those with current or past history of breast cancer, vaginal dehydroepiandrosterone can be given. These can be supplemented with vaginal dilators and pelvic floor exercises

6. Erectile dysfunction in men – First line of pharmacological management is phosphodiesterase-5 (PDE-5) inhibitors; for cases not responding adequately to PDE-5 inhibitors, a trial of vacuum erection device (VED) or intracavernosal injections can be given. If there is no improvement with the above methods, one can consider surgical penile prosthesis implantation

7. For loss of penile length – VED daily

8. Vasomotor symptoms in men – Medications that can be used are venlafaxine, medroxyprogesterone acetate, cyproterone acetate, and gabapentin.

Nonpharmacological management

Sexual dysfunctions are a complex interplay between physiological, psychological, and social factors related to cancer and its treatment. The foremost important factor in resuming a positive sex life is good communication between the partners.[66] They should also be encouraged to view that sexual pleasure and intimacy may include a lot more than mere penetrative intercourse.[59] The first line of nonpharmacological interventions such as CBT, stress management, relaxation training, sexual education, and counseling may help reduce sexual dysfunction in cancer patients or survivors.[67] In couple sex therapy, involvement of both partners working toward enhancing sexual intimacy, communication, and concerns around body image should be addressed.

Table 8 gives the predisposing, precipitating and perpetuating factors to be evaluated and considered in sleep assessment. Communication also plays an important role in navigating through various experiences of sexual dysfunction among cancer patients and their issues around sexuality. A study evaluated sexual functions in people diagnosed with prostate cancer along with their spouses and identified a need for interventions to improve spousal communication and sexual rehabilitation for patient and caregiver.[68]

Table 8.

Predisposing, precipitating, and perpetuating factors for insomnia[53]

Predisposing	Precipitating	Perpetuating
Female gender	Cancer treatments that cause variations in the level of inflammatory cytokines can alter circadian rhythms/disrupt sleep–wake cycles	Increased daytime sleeping
In the elderly, hyper-arousability as a trait	Adverse effects of cancer treatment	Long-term use of prescription/nonprescription drugs
Personal or family history	Menopause	Maladaptive cognitions
Mood or anxiety disorders	Hospitalization
	Distress due to cancer
	Pain, fatigue, or other symptoms
	Corticosteroids/other medications

More intense interventions such as Sensate focus therapy based on Master’s and Johnson’s model of sex therapy, Seeman’s technique, and stop–start techniques for premature ejaculation are required in those where permission, information, and specific suggestion to improve sexual functioning have not been effective.

PSYCHOTIC DISORDERS

Introduction

Psychosis, more commonly schizophrenia, is seen in 1% of the population worldwide. However, nearly 50% of patients diagnosed with schizophrenia had significant delays between the diagnosis of cancer and initiation of treatment.[69] The various reasons for delay are the inability of people with psychosis to explain their distress, the bizarre descriptions may be interpreted as a psychotic or a positive symptom, and a detailed evaluation is delayed. Studies have noted that people with schizophrenia are most commonly diagnosed in advanced stages of cancer.[70] Some symptoms of schizophrenia can emerge secondary to brain tumors and chemotherapy and can be confused with symptoms of delirium. The preexisting or recent-onset psychosis can have a negatively impact on the quality of care, continuity of care, and reaching remission as it is noted that a significant number of people are lost to follow-up in 1 year. The quality of care is further poor in the homeless and institutionalized psychiatric patients.

The difficulty in following instructions makes them more prone to side effects of surgery,[71] chemotherapy, and other treatment modalities. The mortality rates are higher because of adverse events in people with psychosis.[72]

The management of psychosis in people with cancer is just as in general population; the psychiatrist should pay adequate attention to the ongoing cancer therapy and titrate the medications to reduce adverse effects.

Nonpharmacological management

Psychiatrists/psychologists can help in improving coping strategies owing to the changes in personality or behavior as a part of illness. Psychosis is characterized by delusions/hallucinations as a major symptom domain, which is difficult for both patients and their caregivers. CBT for psychosis[73] integrated with other interventions such as hallucination-focused integrative therapy, mindfulness-based interventions,[74] and ACT[75] also have shown to be effective. Psychiatrists with co-ordination in a multidisciplinary team can help the patient in understanding the clinical condition, need for treatment, and assess the capacity to consent and make decisions[70] which can improve the outcomes and QoL.

BREAKING BAD NEWS

Bad news is “any news that drastically and negatively alters the patient’s view of her or his future.” There are various methods employed to break bad news to people diagnosed, living with, or in end stages of cancer journey.

Are two other methods in breaking bad news; the abbreviation and brief description are given [Table 9]. The readers are encouraged to go to the reference material for in-depth understanding of it.

Table 9.

Various protocols for breaking bad news

Spikes - the six-step protocol for delivering bad news[76]	Breaks protocol for breaking bad news[77]
Setting up the interview	Background
Perception of patient to be assessed	Rapport
Invitation to patient	Explore
Knowledge and information sharing to the patient	Announce
Patient’s emotions addressed with empathic responses	Kindle
Strategy, summary	Summarize

The steps and process of breaking bad news is summarized in Box 10.

Box 10.

Guidelines for breaking bad news[1]

Breaking bad news starts with asking questions and assessing readiness of the patient and family to grasp any information that is being conveyed

An appropriate setting and adequate privacy need to be ensured

Next, one should find out how much the patient already knows and whether they want any or more information

After making sure that the patient is ready, the session should progress in a way that patient and family have a sense of control over the quantity of new information that is being received

A “warning shot” or an indication needs to be given at this stage that something serious has happened, after which information is provided in steps

After informing the diagnosis, it is important to pause and acknowledge that the news could have shocked or distressed the person

Further concerns or queries are explored and discussed, and ventilation is facilitated

Session is summarized, and availability for a further session is emphasized

ROLE OF SPIRITUALITY IN CARING FOR THE TERMINALLY ILL[1]

Palliative care aims to keep the person comfortable, pain-free, and healthy in psychological and spiritual domain and also improves QoL until death. Spiritual care is a core component of palliative care. Spiritual health has been defined in relation to various elements such as cancer pain, individual morale, family value systems, grief, death, and bereavement. The two main components are faith/religious beliefs and meaning/spiritual well-being. These two components have an immense role in developing supportive care and end-of-life care. The clinician should be sensitive to important end-of-life care decisions such as resuscitation, ventilator support, allowing for death in the clinical setting versus home, and fears related to death and dying. The end-of-life decisions should be made in discussion with the family. If they choose to keep the person on the hospital or hospice setting, a peaceful environment should be created and the family and loved ones can be allowed to be close to the person. The persons own preferences, family values and religious beliefs must be encouraged and enabled to provide the person with good death. This could mean avoiding the use of narcotics, avoiding excessive pain management, etc. It is important to provide calm in the environment, use of holy water, religious books, chanting prayers/mantras, sleeping in a certain position, and others which in their religion are believed to provide good death. At this time of decision-making, decisions of the patient and the family must be respected and followed even when against the judgment of the clinician; however, basic medical and bodily needs must not be compromised. An ethically and morally challenging decision should be thought, discussed, and made with the family.

CONCLUSION

Psycho-oncology is an emerging specialty which is an intersection between oncology and psychiatry. Psychiatric disorders are increasingly being diagnosed in those with cancer. The psychiatric comorbidities commonly seen are depressive spectrum disorders, adjustment disorders, anxiety disorders, and sleep and sexual disorders. The assessment, investigation, and treatment – pharmacological and nonpharmacological when tailor-made for their specific needs – are seen to be more effective. The role of communication and spirituality cannot be emphasized enough. It is important to identify and treat the comorbid psychiatric illness which in turn will result in the improvement of QoL for those diagnosed/living with cancer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.