Nurses Urged to Be Alert for Depression in Cancer Patients

HOUSTON--About 50% of patients function well when dealing with the diagnosis of cancer, but the other 50% need assistance adapting to the trauma brought on by the disease and its treatment, Debra Sivesind, RN, said at M.D. Anderson Cancer Center’s 2nd Annual Nursing Conference.

Ms. Sivesind, clinical nurse specialist in the Psychiatric Section of the Neuro-Oncology Department, M.D. Anderson, said that she expects patients to display a certain degree of distress in response to a cancer diagnosis. "Patients can be expected to be fearful about the possibility of death, disability, suffering, and disrupted relationships," she said. "It is also natural for them to be angry and sad at having their world turned upside-down. These are normal responses to a cancer diagnosis that can be resolved with the support of family, friends, and caregivers."

But, she added, when the patient’s distress level begins to interfere with his or her ability to participate in treatments, make decisions, or adapt, some form of intervention may be necessary

Oncology Nurses Play a Role in Assessing Psychiatric Illness

Debra Sivesind, RN, said in her presentation at the M.D. Anderson Nursing Conference that nurses are in a strategic position to participate in the assessment and detection of psychiatric illness in cancer patients and to help patients cope with the disorders.

Some nurses are more comfortable in the role of counselor than others. "The keys to empowerment for nurses are good communication skills and self-confidence," she said.

Nurses must be able to elicit sensitive information that is vital to assessment, she said, and they must be objective in how they approach the patient.

"The quality of care is significantly compromised when the patient and the medical staff do not share the same language, beliefs, attitudes, and values, particularly about health, illness, death, and roles of family members," Ms. Sivesind said. "It is important to be open to varying beliefs and to avoid stereotyping."

Nurses must also be cognizant of their own feelings. She cautioned that some cases might evoke latent emotions in a nurse, based on a personal experience of suffering or loss. In such cases, the nurse should not hesitate to solicit assistance from other professionals.

Most cancer patients do not have a history of psychiatric problems, Ms. Sivesind said. "About 90% of the patients who are determined to need some type of psychiatric counseling during the course of their disease are suffering from problems brought on by the cancer or the cancer treatment," she said. "The other 10% have prior psychiatric problems."

One Third Have Depression

Ms. Sivesind said that about 33% of cancer patients will meet the criteria for a diagnosis of depression. Depression is characterized by somatic and psychological symptoms. But when diagnosing cancer patients, somatic symptoms are not a useful measure of depression, she said.

"The somatic symptoms of depression, which include changes in appetite, weight loss, insomnia, psychomotor slowing, and poor concentration, too closely resemble the symptoms of cancer treatments," Ms. Sivesind explained.

Psychological symptoms are more dependable for diagnosing depression in cancer patients, she said. These include depressed mood, feelings of worthlessness, hopelessness, excessive guilt, and preoccupation with death and suicide.

Ms. Sivesind said that signs of hopelessness and suicide should be evaluated thoroughly because of the potential severity of these symptoms.

"For some patients, hopelessness is the realistic acknowledgment that although there is no hope for a cure, pain relief is possible that will allow them to spend quality time with family and friends," she said. However, if the patient’s hopelessness is related to a psychiatric disorder, this realistic viewpoint might translate into doubts about pain control and doubts about living long enough to enjoy time with family and friends. This form of hopelessness is called pervasive hopelessness because it consumes and controls all aspects of the patient’s cognition.

Risk Factors for Depression

Risk factors for depression amongcancer patients include a history of depression treated through counseling or medication, a history of alcoholism, uncontrolled pain, advanced disease, use of certain types of medications, or concurrent illness that is typically associated with depressed mood, for example, hypo-thyroidism and Parkinson’s disease.

Depression can be brought on by certain medical conditions as well as by some medications. For example, metabolic abnormalities, febrile states, anemia, nutritional deficiencies, endocrine problems, and chronic pain have been shown to cause depressed states.

Chemotherapy agents, analgesics/anti-inflammatory drugs, anticonvulsants (phenobarbital, phenytoin, and primi-done), antihypertensive agents, sedatives/tranquilizers, steroids, and stimulants are among the medications that can contribute to depression.

"We have also observed the onset of depression in patients being treated with alpha-interferon," Ms. Sivesind said. "The depression subsides when the dose is reduced, but then the patient does not get the full benefit of the treatment. We have been successful in using antidepressant therapy to counter the psychiatric effects of alpha-interferon."

Delirium an Acute Problem

Delirium is an acute psychiatric disorder; it is usually reversible unless the patient is in the terminal stage of illness. "Delirium usually has a rapid onset, so it is easily diagnosed," she said. An estimated 25% to 40% of cancer patients will develop delirium at some point during their illness. This rate increases to 80% among terminally ill patients.

Delirium impairs thinking and memory. Primary brain tumors, as well as up to 25% of systemic cancers, may contribute to delirium. The most common cancers that metastasize to the brain are breast, lung, colon, and renal cancers, and melanoma. Leptomeningeal disease can cause direct changes in mental status as a result of tumor cells "stealing" blood flow from the cortex of the brain, causing local ischemia and deficits in attention and reasoning.

Radiotherapy, chemotherapy, medications, and biologic agents may indirectly affect cognition. Ms. Sivesind described a study in which lung cancer patients treated with prophylactic radiotherapy to the brain suffered moderate atrophy 2 years later, and one-half had memory loss.

Studies have also shown that when chemotherapy drugs are administered intravenously or intrathecally, there is a higher risk for neurotoxicity than when the drugs are given through other routes.

Biologic agents, such as alpha-interferon and IL-2, and steroids may also cause delirium, as can organ failure, electrolyte imbalances, endocrine abnormalities, and infections, particularly infections of the central nervous system.

Depression in cancer patients is typically treated with antidepressants and psychostimulants, the same drugs used in medically healthy psychiatric patients.

The drug most commonly used in the treatment of delirium is haloperidol, which has been successful in suppressing perceptual disturbance without causing excessive sedation. Benzodiazepines have been shown to worsen delirium, she said.

Supportive counseling is an essential form of treatment for depression. Ms. Sivesind said the goals of counseling are to help patients regain a sense of self-worth, correct misconceptions or negative thinking, and integrate the conditions of their illness into the continuum of their life experience. "We want to help patients validate who they are, gain a sense of hope, and learn to adapt," she said.