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August 10, 2013

Essay on Anxiety and Depression in Cancer

Alternative way to help anxiety and depression in cancer

There is substantial evidence suggestive of the fact that cancer patients undergo considerable and continuing psychological distress linked to different forms of cancer and its medical treatment. The psychosocial management of adjustment problems experienced by people with cancer requires an effective and well-grounded treatment. Nonetheless, there is a heated debate over as to what extent and whether psychooncological care proves effective in the treatment of patients suffering from cancer. 
It should be noted that there are only a few studies that have investigated the overall efficacy of the psychological interventions quantitatively through meta analysis. It is difficult to seek comparison of single intervention studies.  The clinical implications and characteristics of any intervention procedure can obscure the outcomes of measures. It may pose us with certain confusing variables for instance, the patient’s clinical and demographic characteristics such as type of diagnosis, stage and course of disease, medical treatment,  gender, age and the level of education. Secondly, the type and duration of psychosocial interventions, selection of outcome measures can be another disturbing variable.

Intervention examinations must be conducted to diminish the alarming level of depression among them and to ensure low risk for STIs. The healthcare provider must examine the practice of oncology nurses making sure that their packs include psychosocial assessment.  The must serve as intermediaries between the patient and psychiatrist because such a bond is not only a necessity but an indispensible part of care as well. 
             During the treatment of cancer patients suffering from depression and stress, the adherence to national and community standards such as JACHO can ensure and maintain the best practices. The first and foremost step in the treatment of the cancer patient is indeed the assessment of the pain. For that matter, hospital must conduct pain assessment of the patient as this is an integral part of care and does influence the patient’s overall condition and the outcome of treatment.
            It is essential to arrive at appropriate assessment. This is to say, that the organization must make the most of appropriate means for pain assessment.  The entire process of pain assessment should be in line with the set guidelines and patient’s condition and age.
     It is also necessary that the patient’s pain should be regularly reassessed.  In order ensure the best performance and practice, the health care organization must treat the patient effectively and he/she should be referred to another facility for treatment if need arises.
   Hospital and caregivers can develop their own pain assessment tools but they must not overlook the national and community guidelines and standards. 
These guidelines can impact positively the treatment and its outcomes. In order to ensure the best treatment to the ailing patients, one must have full understanding of the patient’s needs. A set of questions related to the treatment process and with an objective to know the preferences of the patients, it will be reasonable to come up with a questionnaire. This would facilitate not only the care giver but the patient as well.
                                              Questionnaire
Q.1   How do you view the whole treatment process?
Q.2   Do you find any deficiency in the method that we have chosen to help you cope with depression and anxiety?
Q-3 Do you require any information about the disease and will this reduce your emotional distress.
Q-4  Do u think that psychological intervention will of any help to in coping with the disease?
Q-5   How much time do you estimate will it take you to recover from the disease?
     Similar kind of questions can added to the questionnaire and the feedback of the patient should be sought. It goes without saying that providing question prompt sheets to patients with cancer during primary consultation serves to bring up all the queries and questions on the part of the patient regarding the treatment and disease itself.
  It is advisable that patients be provided with the information regarding the process they will have to go through since it reduces the emotional stress and escalates the psychological and physical recovery. If the patients are given the practical and basic details about the treatment procedure in the form of a booklet or a videotape, the anxiety and psychological distress is reduced. 
The patients must know what they are going experience (pain) before, during, and after the procedure because it lessens anxiety.  The proper psychological support to the patient especially prior to surgery reduces stress.
Cognitive behavioral, psychoeducational, and crisis interventions, as well as combinations of educations and behavioral or non-behavioral interventions and anti-anxiety medications can yield best results in the treatment of anxiety.  Supportive psychotherapy coupled with antidepressants, serotonin reuptake inhibitors for example, can be an effective technique to deal with and manage the post-traumatic stress disorder.
  There is no evidence suggesting the superiority of any antidepressant in the management of the depression among cancer patients.
   The concept of comprehensive care of cancer patient responds to both an expectation of
patients and their relatives as well as. However, this approach involves theoretical references and a clinical method. "The oncology supportive care is defined as the all care and support
needed for those patients throughout the disease together with treatment.  
This holistic approach assumes that the sick person all those involved in care
involved in cancer takes into account the size of the supportive care in the management
of their patients, especially in terms of continuity of care.
The whole process of care involves the best possible quality of life for patients throughout the disease, the physical, psychological and social aspects taking into account the diversity of
needs of those around them and whatever their health care settings are. Supportive care is not a new specialty but is defined as a coordinated organization of different skills involved in conjunction with care specific oncology in the care of patients. "


This psychoanalytic approach was introduced by Pierre Cazenave, a cancer patient himself. He founded "Centre psyche and cancer" for patients who, like him, wondered about the meaning of their illness. From his intuition about his own illness, he spent most of his practice to patients with cancer and with According to the psychoanalyst Pierre Cazenave, the cancer patient suffers from an identity disorder. There would be a fault at the primary narcissism. In the primary narcissism, or in the psychosexual development, the love object of the child is his own person contrary to secondary narcissism when the object of love is usually outside.
Thus, primary narcissism is the "glue" of personality and it promotes the unity of the latter. In people with cancer, there would be a vulnerability of personality fragmentation from very early periods of childhood or even archaic. It is the theory of "the disease of infants in the adult”.
In the current biological theory of cancer, the body produces regular cancer cells and these are eliminated progressively by the immune system. Cancer occurs when there is a break in this dynamic occurring as a result of two distinct phenomena: either the body begins to produce a greater number of cancer cells and the immune system cannot cope is "overwhelmed" is the number of cancer cells but does not change the immune system which is not working properly.
 Finally, these phenomena could be caused by psychological trauma. Cancer is a disease in which the narcissistic patient is tormented by the feeling of not existing. Either because the image of the mother is not integrated either because it is too intrusive or the link cannot be broken by the child who can live with this overflow.
The treatment of cancer patient suffering from depression is  fraught with dangers especially when the ethical dimensions are not satisfactorily addressed. In a relationship to the patient, the work of the psychoanalyst must be neutral and not subjective; the difference being that one has the right to be touched by the patient's story without being completely immersed in emotion. His job is to adopt the distance right and necessary and readjust whenever necessary, the key is to not give in to the urge to protect himself only.
The analyst must therefore work on himself to learn to accept his own faults, aware of his own weaknesses and seek to help the patient in coping with depression and stress.  to discover his own and accept them as part of the vagaries of life. This allows him to put himself , subjectively, in tune with the patient.  
Unlike science, the psychoanalyst does not work with his theoretical knowledge because it is based on assumptions and not on proven truths.
             Over the past twenty years, there has been a growing interest in social and behavioral issues related to cancer and discipline was constituted---the psycho-oncology and psychosocial oncology.
The growing interest in the study and application of psychology to cancer is due to:

a) The fact that the influence behavior or determine a large number of cancers, so that 80% of them are due to environmental contribution that determines his or her appearance during the habits such as smoking, eating behavior , weight, etc having a major influence in the development of cancer. Control of risk behaviors and adoption of healthy lifestyles can save more lives than all the existing procedures of chemotherapy.

b) Early detection of certain types of cancer such as breast or prostate cancer, is highly critical in survival.

c) Advances in psychophysiology and psycho-neuro-immunology have revealed pathways through which stress and emotions can contribute to the genesis, prognosis and survival of cancer patients.

d) The need to properly inform the patient about the diagnosis, prognosis and treatment of disease, to make decisions on information content, the most appropriate channels, the sequence and style of issuing this Information .

e) The development of procedures for assessing the quality of life of patients is needed for orientation and decision making on medical treatment. This evaluation includes psychological state (anxiety, mood, adjustment to illness, etc.) Physical symptoms associated with disease course or treatment involve pain, effects of chemotherapy, body image, sexual problems etc..

f) The emotional impact associated with the diagnosis and course of the disease are necessary evaluation and appropriate treatment for both the patient and relatives.

g) The scope of the change of conduct has developed techniques that allow for appropriate treatment of symptoms associated with treatment conditions during the illness which seriously affect the quality of life of the patient, such as conditioned responses to chemotherapy, sexual problems etc.

Thus, the contribution of psychology to the field of oncology can be divided into two main areas: firstly, the study of psychosocial factors that may affect the etiology or course of the disease and on the other hand, it can be used as an intervention for improving quality of life of cancer patients.


 

Anemia is common in cancer. This is a consequence of the disease and chemotherapy and it is aggravated by radiotherapy. It is accompanied by severe fatigue, forcing patients to significantly reduce their daily activities. Anemia also contributes to tumor hypoxia (oxygen deficiency), which induces resistance to chemotherapy and radiotherapy. Ultimately, this condition affects the quality of life, having a negative impact on the response to treatment, relapse-free survival and overall survival. It is therefore essential to screen for anemia in cancer patients and to treat it.
Transfusions are effective, but accompanied by viral and bacterial risks, they are reserved for serious and urgent clinical situations. It is used today for EPO (recombinant human erythropoietin), a well-tolerated and very effective method that results in a significant and self-evident improvement from the third week.
                             Emotional distress, helplessness, loss of self esteem is disorder that accompanies cancer. Now they promote a state of depression, fatigue while maintaining or even exacerbating the depression. The challenge is to differentiate the psychological component of fatigue, that inherent to the disease and its treatment. If depression is diagnosed, a psychosocial support group or individual psychotherapy is helpful. This intervention may be associated with drug therapy.

Therapeutic advances in oncology have improved the efficiency of treatments, to reduce the inherent risks and improve the assessment of cancer-related diseases. They are becoming more and more long-term pathologies. Despite constant advances in treatment, the social representation of cancer remains associated with death, pain, powerlessness and uncertainty about the future.  Depressive episodes occurring in patients with malignant diseases have in common with all other depressions. The prevalence of depressive episodes in patients suffering from cancer is significantly higher than general population.
              Thus, 20 percent of patients diagnosed with cancer during the 12 months above suffer from a depressive disorder.
In some patients, these two diseases may occur independently from each other. This scenario is relatively rare.  Many studies have shown that depression or depressive symptoms would be involved in the occurrence of certain cancers. Some cancers may be the cause of depressive syndromes. This is the type of the most common relationships. The mechanisms involved may be of three types: biological and / or lesions; Iatrogenic, which will be discussed systematically.
              Psychological depression occurs in response to physical illness and it imposes bereavement: loss of his physical health, social role, the possibility of changing his family, mourning his medical intensive care. These mechanisms are not exclusive of each other, and, for most patients, several mechanisms are entangled among the precedents. The first reaction could quickly lead to the conclusion that depression is not the disease area and does not require specific treatment.
               It would ignore the consequences of depressive episodes, now well known.  The worsening of the prognosis of malignant disease and the increased mortality is particularly due to poor adherence to medical treatment or even denial of care. Recent studies have also shown that patients with depression did not see themselves being offered the same medical treatment as other patients, as if the doctors gave up some therapeutic methods in depressed patients, thereby forgetting that depression is not inevitable, but a condition that is treatable and can be cured in most cases.
                Some cancers, however, often involve tumors of the pancreas, the sphere ENT or genital area, for example. The depressive episodes can occur at all stages of diagnosis, treatment and patient outcomes.



Distress and stress management for cancer patients
The diagnosis of cancer is a major cause of stress. Although progress in therapeutic process has changed the image of cancers in everyone's mind, evoking the diagnosis of cancer always returns the patient to the possibility, concrete and short term of his own death. A stunning anxious reaction frequently follows the diagnosis and therapeutic possibilities, and is often accompanied with a sense of loss of body control and life and fear of physical disability. This reaction can give way to a longer episode of depression.
Thus, the first month after diagnosis is a time of high prevalence of depression among cancer patients. It is not uncommon for depressive disorders with the waning of the stay treatment, even if these have been the source of therapeutic success and if the somatic state of patients is improved.
Due to advanced treatment, these cases are becoming even more frequent. The lower doses of steroids and physical exhaustion and induced psychological treatments may also play a role in the onset of these episodes.
 This is a step physically and psychologically difficult. It can promote the emergence of a depressive episode.  As a complication of treatment, adverse effects of chemotherapy or radiation treatments as asthenia, alopecia may promote the emergence of depressive episodes by physical effects (size of exhaustion) and psychological (changes of body image in particular). 
               Some drugs used in cancer treatment may also have iatrogenic effects of depression. Examples include the treatment with corticosteroids, interferon alpha, interleukin, vincristine, vinblastine, or dacarbazine. When considering the possibility of an iatrogenic factor, it will take as much as possible and in consultation with doctors, trying to control them.  In a context of chronic pain and end of life: depressive episodes are common in this context. They were covered in module pain - palliative care - death. “The renunciation of curative treatments and disinvestment on the part of health care teams are often factors
contributing to depressive episodes in cancer patients.”
            Today, depressive episodes are insufficiently diagnosed and treated at patients with malignant diseases. A recent study shows that in medical oncology services, less than 50% of depressed patients are identified as having psychological distress and referral to a psychiatrist.
      Caregivers fear inducing psychological distress in addressing the issue of psychological suffering, they sometimes they do not have the sufficient expertise to address such issues and may be afraid of other methods to deal with patient’s depression. It is noteworthy that the psychological suffering of the patient should be expressed,
heard and taken into account and that each caregiver should be able to question on psychological reactions aroused in him and analyze the suffering of his patient.

      Some patients have incomplete symptom charts, reaching the threshold of depressive episodes characterized, and occur in response to a stressor occurred within three months. Such stress may be the revelation of the diagnosis of cancer, the announcement of a treatment or mutilating the announcement of a relapse, for example. For these patients, the classification offers a diagnosis of "disorder of adaptation with depressed mood”
Suicide occurs in the immediate aftermath of diagnosis (18%) during remission (42%) or terminally ill (30%). The means used are more violent than the general population (defenestration, hanging). As in the general population, male gender is a risk factor age and peaks are found (young adults and elderly).
Risk assessment of suicide is an essential point which will determine in part the approach of therapy. It rests, not on a single parameter fully reliable on its own but on an array of arguments.  Among depressed cancer patients, risk factors of suicide are more specific: pain symptoms, the major problems of body image, severe complications of treatment
(eg neuropathy secondary to chemotherapy), and the very negative views of care options.
           In cancer patients, we can find vulnerabilities depressive unique to each individual and factors which are more specifically associated with cancer. It is they who hold our attention.
It seems that the mode of psychological adjustment to illness (modes of "coping") that can best predict the onset of a depressive episode in a
cancer patient.
               Patients who are able to find an explanation for their disease have, in general, a better adaptation to their illness. The questions they often ask include "Why me?", "Why now?", "What have I done to deserve that? “ Patients often infer that their cancer is the result of their personal fragility, their inability to cope with a situation or to express their anxiety in certain situations. Sometimes they attribute to others the responsibility for their disease.
           Patients cope better with their disease if they think they can contribute to healing. Thus, in general, patients who are active in organizations or groups of patients, using techniques such as relaxation, diet, yoga have a better prognosis than the others, unless their way to fight against their illness becomes an obsession around which their whole life is organized.
              Similarly, patients cope better with their disease if they could talk to their entourage, rather than if they keep this information "secret." The perception by the patient's caregiver support is another important element. A quality monitoring, coupled with appropriate information and a good listener, can help prevent the occurrence of certain depressive episodes.

Some caregivers sometimes have difficulty communicating with cancer patients.  
This leads them, consciously or unconsciously in most cases, to avoid contact with patients, unless they are absolutely necessary. There is a risk factor for developing a depressive episode for patient.
              The foregoing should be systematically searched with a cancer patient and should be an integral part of therapeutic work. The therapeutic context calls for a necessary interaction between caregivers and the patient.(Irving & Williams, 20010) The treatment of depression must be based on good coordination between caregivers, psychiatrists, and psychologists.    This must aim at exchange of information, to enable caregivers to express and manage their own difficulties, to allow the patient to receive information as relevant as possible about her illness and prognosis, and develop a common therapeutic strategy.
          Hospitalization should be moved (or, in rare cases, imposed) in cases following: if severe melancholic depression, when suicide risk is important.
          Treating depression and associated somatic disease is a crucial point. The only treatment of cancer through medication will not, in good standing generally, curing depression, and vice versa. It is one of the early stages of treatment of depression in cancer patient.  
            It is based on several points articulated around the risk / benefit ratio. The first is the need for an effective antidepressant. Studies show that antidepressants are less effective in patients with somatic diseases among others. The causes of this phenomenon are probably multiple. We include intrinsic efficacy lower tolerance inducing sometimes poor and low compliance with treatment, and finally pharmacokinetic interactions.
              The second point is the consideration of associated properties, the effectiveness over the painful symptoms. The third point is the need for a well tolerated antidepressant.
 Taking into account the pharmacokinetic interactions is essential, especially polymedicated in the subject, in subjects with renal or hepatic kidney, in subjects receiving treatments that bind to plasma proteins (AVK) or inhibiting cytochrome P450 systems.
  Taking into account the pharmacodynamic interactions is equally important.
Examples include the anticholinergic properties, properties, alpha 1 blocking, guanidine-like effect of tricycle antidepressants.  It is also useful to consider the adverse effects of the specific molecule. We avoid such antidepressants because it can induce nausea in cancer patients treated with emetogenic chemotherapy.
 Standard effective doses are established in patients presenting no somatic diseases. Patients 'somatic' are particularly sensitive to adverse events and are subject to pharmacokinetic interactions and Pharmacodynamics. We begin treatment with relatively low doses and we increase doses more slowly.
 There is very little data on this subject since the available studies have time ranging typically between 4 and 8 weeks. Given the risk of relapse and recurrence that exists in these patients, the time now recommended is at least 6 months after complete remission.
       They have an essential role in treating depressed patients with a malignancy. They include patient’s education on depression, antidepressants and their relationship with somatic disease, information for caregivers and somaticians to seek their collaboration, interventions with the family, and psychotherapies, including support, or using body language.
Supportive psychotherapy should be offered to all patients. It allows patients to discuss their problems and express their feelings without fear of being judged. These patients sometimes have a pessimistic view about the course of their disease and feel that further treatment is
unnecessary. Especially in the early stages of cancer, patients and their families need to be informed, encouraged psychologically. Subsequently, they need help to accept and adapt to the disability physical or diagnosis of incurable illness.

                                                                         Reference
Polinsky, M. L. (1994). Functional status of long-term breast cancer survivors: Demonstrating chronicity. Health& Social Work, 19, 165-173.

The NCCN, (2010) “Distressing Management Clinical Practice Guidelines in Oncology”
Journal of Holistic Nursing, (2010) “Feasibility of a Mindfulness-Based Stress Reduction Program for Early-Stage Breast Cancer Survivors”


Irving G, Lloyd-Williams M. (2010) “Depression in advanced cancer” Eur J Oncol Nurs.

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