Psychiatry Consultation in a Patient With Early Breast Cancer

Ms. L is a married 41-year-old woman with recently diagnosed stage I breast cancer. She comes to her oncologist's office for a routine visit following her third cycle of preoperative doxorubicin hydrochloride (Adriamycin) and cyclophosphamide (Cytoxan). Ms. L's major complaint is fatigue. The oncologist had started Ms. L on paroxetine (Paxil), a selective serotonergic reuptake inhibitor (SSRI), at 20 mg qhs 2 months earlier because of concerns that Ms. L might be depressed, based on her complaints about depressed mood, difficulties sleeping, and other depressive symptoms.

The clinic nurse observes that for the first time, Ms. L's spouse has not accompanied her to the appointment, but instead, Ms. L's 17-year-old daughter has come with her. She questions Ms. L regarding how her family has been managing the stress of her cancer and treatment. Ms. L acknowledges that she and her husband have been experiencing tension related partly to sexual difficulties, and her children have seemed increasingly angry about her illness. The clinic nurse asks Ms. L if she has been seeing a mental health professional. Because Ms. L indicates that she has not, the clinic nurse refers her to a local psychiatric practice.

Psychiatry Consultation & Treatment Summary

Ms. L arrives for her appointment with the psychiatric nurse practitioner, who conducts a thorough review of Ms. L's history, including her breast cancer diagnosis and treatment. The nurse practitioner inquires about the symptoms prompting initiation of paroxetine, and her current symptoms.

Ms. L reports initially experiencing fatigue, depressed mood, insomnia, diminished interest in her usual activities, and difficulty concentrating, but describes these symptoms as fluctuating considerably. Now, she complains that she feels very sluggish, and she has developed sexual difficulties involving loss of desire and difficulties with arousal as well as orgasm.

Paroxetine helped improve the patient's mood slightly, as well as her interest in activity and her insomnia, but now she is sleeping too much. Ms. L denies having suicidal ideation, or feelings of guilt or worthlessness, and she also denies any major persistent changes in appetite or weight.

Of significance is that Ms. L experienced depressive symptoms 8 years ago and was treated with fluoxetine (Prozac) by her family physician for only 3 months with good results. Ms. L denies any other periods of depression or any family history of psychiatric illness.

The nurse practitioner diagnoses Ms. L as having an "adjustment disorder with depressed mood, rule out a major depressive episode." Free thyroxine and thyroid-stimulating hormone levels are ordered, along with a complete metabolic profile, to rule out possible physical causes of her complaints. The nurse practitioner reassures Ms. L that she probably does not have a major depression, and suspects that paroxetine may be at least contributing to some of her complaints.

Since Ms. L's functioning is being impaired by her symptoms, the nurse practitioner suggests a change in medication. Ms. L agrees to taper her paroxetine, and to begin bupropion to lessen fatigue, daytime sedation (both possibly induced by paroxetine), and sexual dysfunction (which may have been induced by the SSRI as well as by other factors, including her adjustment to her breast cancer diagnosis, treatment, and treatment side effects).

The nurse practitioner instructs Ms. L as to the common side effects, including insomnia, agitation, gastrointestinal disturbances, and headache.[1] Ms. L agrees to come in every 2 to 3 weeks for medication follow-up and supportive therapy.

Outcome

Ms. L tolerates the bupropion and finds significant improvement in her mood, interest in activities, sexual function, and sleep. Throughout the remainder of her chemotherapy she experiences fatigue, which she finds is lessened by the bupropion. She participates in individual as well as family therapy, and family relationships improve.

Discussion

This case illustrates several points regarding depression assessment in the oncology setting, and the benefits of psychiatry consultation. In many situations, oncologists make an effort to treat depression when it is detected, and Ms. L's oncologist may have used sensible judgment in attempting a trial of paroxetine to target the initial complaint of insomnia while avoiding potentially stimulating effects of the fluoxetine she had taken during her first episode. Yet the patient reported good results with fluoxetine, and it is practical to initiate therapy with a previously successful agent barring any rationale to avoid using the same agent.[2]

Referring Ms. L for psychiatry consultation at an earlier date might have eliminated some of her difficulties. Generally, individuals with histories of depression or other psychiatric disorders warrant frequent, thorough assessment and prompt referral upon the development of symptomatology. Nurses have some knowledge of depressive symptoms, and self-report ratings can assist in assessment.[3]

The clinic nurse did not explore the history of Ms. L's current complaints, coming to the conclusion that Ms. L and her family simply needed support without more fully exploring the problem. Given that the oncologist prescribed the paroxetine, the nurse, in collaboration with the oncologist, should have routinely assessed medication effectiveness, tolerability, patient adherence, and possible side effects.

If the clinic nurse had asked more questions, she might have then been able to see the possible connection between the sedation, sexual dysfunction, and paroxetine use. As often occurs with psychiatry referrals, the stated referral rationale was not an accurate reflection of the actual underlying problem.

Another issue in Ms. L's situation is the diagnostic uncertainty regarding the actual presence of depression, which carries implications for treatment. Ms. L reported having multiple depressive symptoms prior to the initiation of the SSRI, but her symptoms did not clearly appear to have had the persistence (ie, occurring on most days over at least a 2-week period) required for diagnosis of a major depressive episode according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders text revision (DSM-IV-TR).[4] Therefore, and given the clear association of Ms. L's symptoms with the stress of her cancer diagnosis, an adjustment disorder was suspected.

Many clinicians are inclined to defer pharmacotherapy for an adjustment disorder unless symptoms are sufficiently severe to cause significant distress and problems with daily functioning.[5] On the other hand, a history of depression is a risk factor for recurrent depression,[2] and the failure to successfully treat poses many significant dangers.[6] Thus, the nurse practitioner wisely treats Ms. L's symptoms. Bupropion, a norepinephrine and dopamine reuptake inhibitor, causes less risk to sexual function and may actually improve it; because of its activating nature, it is more likely to target Ms. L's symptoms.

Nurses play a major role in the care of depressed patients, significantly impacting quality of life. They may intervene directly, as in teaching patients about their medication, providing support, or reinforcing self-care, but they also need to be aware of the available community resources.[7]

References:

1. Maxmen JS, Ward NG: Antidepressants, in Psychotropic Drugs: Fast Facts, 3rd ed, pp 95-176. New York, WW Norton & Co, 2002.

2. Schwartz L, Lander M, Chochinov HM: Current management of depression in cancer patients. Oncology 16:1102-1110, 2002.

3. Sharp K: Depression: The essentials. Clin J Oncol Nurs 9: 519-525, 2005.

4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed. Washington, DC, American Psychiatric Association, 2000.

5. Van Fleet S: Assessment and pharmacotherapy of depression. Clin J Oncol Nurs 10:158-161, 2006.

6. Rodin GM, Nolan RP, Katz MR: Depression, in Levenson, JL (ed): American Psychiatric Publishing Textbook of Psychosomatic Medicine, pp 193-217. Washington, DC, American Psychiatric Publishing, 2005.

7. Albright AV, Valente SM: Depression and suicide, in Carroll-Johnson RM, Gorman LM, Bush NJ (eds): Psychosocial Nursing Care Along the Cancer Continuum, 2nd ed, pp 241-260. Pittsburgh, Oncology Nursing Society, 2006.