Anxiety and depression are associated with cancer diagnosis and treatment, and healthcare providers should assess pharmacologic and nonpharmacologic management options when developing a plan of care. Promoting patient resilience is also important and improves quality of life.
Jane Rosenthal, MD, FAPM, from New York University Langone Medical Center, discussed treatment and management options patients suffering from these disorders during a session at the 42nd Annual Congress in Denver, CO.
Rosenthal noted that patients with cancer are at a high risk for suicide, and healthcare providers should distinguish between passive suicidal thoughts (e.g., “It would be better if I didn’t wake up.”) and more active suicidal thoughts (e.g., does the patient have a plan or intention to carry out a suicide?). Risk factors for suicide include those with a history of depression and suicidal ideation, advanced disease, social isolation, age older than 55 years old, male gender, uncontrolled pain, physical and emotional exhaustion, delirium, or alcohol and substance abuse.
Anxiety occurs in approximately 30% of patients with cancer and is most prominent around the time of diagnosis, anticipation of tests, recurrence, news of disease progression, end of treatment, and end of life. Some patients describe symptoms that are similar to post-traumatic stress disorder (including hypervigilance, flashbacks, and nightmares), and other manifestations of anxiety include worry, free-floating anxiety, and ruminations, as well as tachycardia, tachypnea, shortness of breath, tremors, insomnia, and anorexia. Fatigue is another psychological symptom that can occur in 70%–100% of patients.
Rosenthal discussed treatment options, noting that 50% of patients with cancer receive at least one psychiatric medication during the course of treatment. “It is vital to have knowledge of these medications in terms of their possible benefits and side effects, including important pharmacokinetic and pharmacodynamic drug-drug interactions,” she said.
Antidepressants are beneficial for depressive symptoms and chronic, recurrent anxiety (at lower doses). Daily adherence is key, and it is recommended to “start low and go slow” in terms of dosing. Providers should be cautioned to watch for gastrointestinal side effects, nausea, sedation, sexual dysfunction, and headache. Antidepressants should not be combined with other serotonergic medications, such as fentanyl, meperidine, tramadol, and linezolid, which can lead to autonomic instability, mental status changes, clonus, myoclonus, and hyper-reflexia.
Anxiolytics are commonly used for nausea, anticipatory anxiety prior to testing, muscle spasms, and as an anticonvulsant. For benzodiazepines, specifically, short-term use is recommended, and side effects can include sedation, dizziness, ataxia, frequent falling, anterograde amnesia, irritability, behavioral disinhibition, disorientation, and delirium, particularly in older patients. These medications also have a risk for the development of tolerance and addiction, and they should not be stopped abruptly.
Stimulants can help with cancer-related fatigue, improve depression prior to antidepressants, stimulate appetite in low doses, combat sedating effects of higher-dose narcotics that are necessary for pain management, and improve cognition. These agents should be used cautiously at low doses, and side effects can include anxiety, agitation, restlessness, insomnia, and elevated heart rate and blood pressure.
Major tranquilizers and antipsychotics can be used for a variety of symptoms, including:
- Delirium (off-label)
- Anxiety that is refractory to benzodiazepines
- Steroid-related side effects
- Appetite stimulation
Side effects for these agents include metabolic syndrome and weight gain, and providers should watch for extrapyramidal side effects (restlessness, tremors, Parkinson-like symptoms) and hypotension.
Rosenthal also discussed nonpharmacologic treatment options, which are an important part of care. Supportive psychotherapy, including cognitive behavioral therapy, stress reduction exercises, and support groups are recommended. Exercise improves energy, sleep, and immune function while also decreasing fatigue, pain, and risk for anxiety and depression. Complementary treatments, such as massage; acupuncture; reflexology; yoga; music, dance, and art therapy; and journaling, are also recommended.
Lastly, Rosenthal recommended the promotion of resilience through enhanced sleep patterns, increased exercise, improved nutrition, psychological and emotional outlets, and stress mitigation through meditation, tai chi, and yoga. Resilience is “important for our patients...our patient’ families...and for our staff,” she concluded.
Rosenthal, J. (2017). Caring for the mind: Managing depression and anxiety. Session presented at the ONS 42nd Annual Congress, Denver, CO, May 5, 2017. Retrieved from https://ons.confex.com/ons/2017/meetingapp.cgi/Session/1050