Double Trouble – Cancer and Depression

MD Anderson Cancer Center

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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas M.D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today, on Valentines Day, fittingly, we have our guest is Dr. Alan Valentine. He is the Interim Chair of Psychiatry here at M.D. Anderson. And we're going to be talking today about mental illness and psychotherapy in the cancer setting. Welcome to you Dr. Valentine.

Dr. Alan Valentine: Thanks for having me.

Lisa Garvin: I've seen in my years at M.D. Anderson quite a bit of growth in the psychiatry department which started out just as a kind of arm of one of our care centers, but now it's really grown. Tell us about the field of psycho-oncology.

Dr. Alan Valentine: The field, this basically is the field of the emotional consequences of cancer and to some degree the--neuropsychiatry of cancer. This is an aspect of supportive care that is growing, following on what our colleagues in pain have already established. It is now a recognized national imperative. The Institute of Medicine came out with a report within the last two years saying that the emotional care of cancer patients is a requirement for comprehensive total care of the cancer patient and as result having that sort of a national reinforcement has been a great benefit as we start to develop our resources here.

Lisa Garvin: And you've been here a long time, so you kinda started out kind of barking into the wind as it were, you are kind of alone in your field, were you not?

Dr. Alan Valentine: It was a--it was what might have been thought of as something of a--of an orphan field. But as our colleagues have had much more success and--and if not always curing cancer but then definitely making cancer a chronic illness that can be lived with, and the quality of that life has become much more important and that's part of where the emotional aspect of living with a disease comes from.

Lisa Garvin: Well, tell us, let's first talk about people who may be coming in mentally healthy but then develop issues once they get cancer. What are some of the triggers that may cause anxiety and depression in the cancer patient?

Dr. Alan Valentine: Well, the diagnosis itself. Many--many individuals will say that the cancer diagnosis among the diseases that all of us are vulnerable to is among the most frightening that compared to heart disease and other diseases that the emotional valence, the fear, the concern is just greater with cancer. And that's pointed out by the fact that rates of depression are higher in cancer than they are in other serious illnesses. There's been--this is a disease that just with some reason, at least at some point, scares people. And so there is a sort of understandable rate of anxiety, possibly fear, possibly depression that--that happens going forward.

Lisa Garvin: Among the population of cancer patients, what would be the prevalence of the anxiety depression and other symptoms?

Dr. Alan Valentine: It's thought and going back in--in numerous studies that at some point in the cancer trajectory, somewhere between 30 to 40 percent of our patients will experience emotional distress at a level that--that justifies intervention.

Lisa Garvin: And how many of that 30 and 40 percent are actually asking for or seeking help?

Dr. Alan Valentine: That we don't know, which is part of our problem. The--the stigma associated with mental illness generally is such that folks don't like to talk about it, that the situation is certainly better than it was. But many patients, we expect that we will handle our own burdens. And the stigma that is associated with mental illness in the general population unfortunately extends to emotional distress in the cancer population as well. It's not something that a lot of our patients like to admit.

Lisa Garvin: And I would think--especially somebody who would consider themselves mentally healthy would really hate to admit.

Dr. Alan Valentine: Well, yes which and--which is very typical of our M.D. Anderson patient population. We have a very high functioning patient population driven successful and it's a hard thing for some individuals to admit.

Lisa Garvin: What would be some of the symptoms that some cancer patients might, you know, be aware of in their journey to seek help? I mean are there certain things that standout that they should really ask their doctor about?

Dr. Alan Valentine: Well, the two major ones are likely going to be anxiety and depression. And these are not necessarily major depression, the full blown illness, though that is prevalent. But certainly the emotions associated with depression, the emotions of anxiety. And these are things that on a day to day basis we all experience. But if we cope with them they're not a problem. If they get to a point where our normal copping mechanisms are not working for us, they can interfere with our--with care, they can interfere with treatment, they can interfere with our lives away from the cancer center. And when that happens, when it crosses that threshold, which is different for every individual, that's when we would like to ask our patients to intervene or ask for an intervention. And that's what we're screening for. We're--we're now trying to institute a comprehensive model of screening for emotional distress in our patients.

Lisa Garvin: Somewhat similar to the Wong-Baker FACES Scale where they can like pick something along this spectrum.

Dr. Alan Valentine: Something along those lines that will likely be a Likert scale and just sometimes just asking the question, seeking a level of emotional distress that would warrant intervention.

vAnd when you intervene, I'm guessing that a lot of it is pharmaceutical interventions and--and therapy as well?

Dr. Alan Valentine: Both, the thought is that, you know, psychiatry is largely medication based. In a lot of ways it is, but much of the psychosocial care if not the majority of the psychosocial care that's provided at M.D. Anderson involves psychotherapy, and that's--that's largely supportive psychotherapy. It's nothing that falls into some of the specialties that occur in the general psychiatric realm. But it's trying to find ways to help people cope, in addition to sometimes using special techniques like cognitive behavioral therapy.

Lisa Garvin: And I do know that it kind of goes hand in hand with our complimentary therapies. I'm assuming that things like--that we offer at the Integrative Medicine Center, things like tai chi and guided imagery and things like that, those can also help with these symptoms.

Dr. Alan Valentine: They certainly can especially for sub disease level symptoms. And there's actually some evidence--considerable evidence that suggest that even for the major disorders they can be quite helpful. And in the worst case there--they are side effect free. They're gonna help but they're definitely not gonna hurt. So we're--we are for all interventions that will help the patient that are safe.

Lisa Garvin: Well, if you--if you do have to turn to drugs like SSRIs and other antidepressants, is that a challenge when you're managing somebody in active cancer treatment who may be on a whole set of chemotherapy drugs?

Dr. Alan Valentine: It's a potential challenge. It's a potential challenge in the community because not all prescribers are familiar with the cancer treatments and therefore they may not be aware of drug interactions. And for those of us who specialize, it can be a challenge on a case to case basis. Fortunately, the majority of the cancer chemotherapies are not problematic though some of them are. We do have to watch out for drug interactions and there are some, some times that there are some combinations that we would rather try to avoid.

Lisa Garvin: Now, what about the person with preexisting disease? And this ranges from clinical depression to schizophrenia and other major disorders. How often do you see that in the cancer setting?

Dr. Alan Valentine: Well, we believe that we see that at approximately the rate that we would see it in the--in the community, though we're not sure about that. Because patients with severe psychiatric disorders, the nature of that disorder may be such that they don't get the proper medical care that they need for a lot of different reasons. But schizophrenia and bipolar disorder are prevalent in the general community at rates of 1 to 1.5 percent. We would expect that at least that percentage of our patients coming in might be vulnerable to those disorders. Patients with severe psychiatric disorders traditionally are at risk for poor healthcare across the board, not only because of the severity of the illness but lack of access to resources. Those patients can be a challenge to take--to take care of.

Lisa Garvin: Have you have that in your experience, somebody with a really serious preexisting disease that also has cancer?

Dr. Alan Valentine: We see it relatively routinely and we at M.D. Anderson, we specialize in cancer psychiatry but we--it is part of our mission to act as bridge while our--while these patients are receiving their specialty care here. We do our best to try to, especially on the in-patient service, we try to do our best to make sure that those disorders remain under good control. It's better for the patient, it facilitates their cancer care.

Lisa Garvin: And do you ever have patients with--like Down syndrome and other congenital mental disorders?

Dr. Alan Valentine: Occasionally. Our colleagues in the pediatrics division may see some of those patients a little bit more often. But certainly we--we from time to time will see our adult Down patients, patients with mental retardations or borderline intellectual function of all different types. And those patients with appropriate care are successfully treated.

Lisa Garvin: And I guess in that role somebody with any sort of mental disorder or problem it would be good to have a strong caregiver I would think to kinda?

Dr. Alan Valentine: It would almost be essential our--one does not want to stereotype it, and what might assume that our--some of our patients might benefit from, you know, extremely consistent caregiver support. There a lot of decisions that needs to be made. It's possible that some of our patients may be a little bit more vulnerable to side effects than some of--some of our other patients.

Lisa Garvin: So was there any sort of clinical research involving psychiatry that you're involved with in M.D. Anderson, are there things you wanna know and discover?

Dr. Alan Valentine: There are--there are a number of things that are being done by a number of different apartments and divisions at--at M.D. Anderson. They--the current Department of Psychiatry as it's constituted is largely a clinical department, but that's about to change. Our colleagues in behavioral sciences and the symptom control divisions are looking at the multiple symptoms that may have common etiologies, pain, general sickness behavior, fatigue, depression all may have common underlying biological mechanisms. Those are being studied now. There is certainly interest in our group for looking at outcomes, of looking at the impact of altered mental status on outcome delirium which is something that I'm interested in. Some members of our group now are interested in collaborating with our colleagues in integrative medicine, and novel nontraditional pharmacologic interventions to try to treat depressive symptoms and anxiety. So the--the field is sort of wide open right now. Sort of consistent with what's going on outside of psychiatry and trying to find causes of psychiatric disorders.

Lisa Garvin: What about Alzheimer's disease? I would think in our patient population that we would see quite a bit of Alzheimer's in all stages.

Dr. Alan Valentine: We will expect to see the same rate of Alzheimer disease that is--is unfortunately gonna hit the general American population. Our cancer population would be expected to become older because the population is becoming older. The patients with cognitive impairment overall are likely to be more vulnerable to the more severe side effects of our treatments or of cancer because their cognitive reserves are not as great. With that said, there is an increasingly aggressive both research and clinical practice that involves the care of geriatric patients. So despite the fact that we are seeing an older population including those with impairment, treatment is definitely being offered to those--those folks. But we do have to--we have to watch out for them because they may be at risk for more psychiatric side effects.

Lisa Garvin: So in closing Dr. Valentine, what would be the one message you would say to cancer patients about preexisting or, you know, mental disorders that may occur after treatment?

Dr. Alan Valentine: That it's there, it happens, and that unfortunately, there is a stigma that's associated that--that we wish we could find a way to minimize. Emotional distress is common in cancer. It may not be normal but it is not a sign of weakness. It is not a sign of vulnerability for which one should be ashamed. And we would hope that our patients and their families, we think that's its okay to ask for help. And we would ask our clinical colleagues to also think that it's okay just to seek out our patients and ask them about their--the way that they're coping emotionally.

Lisa Garvin: Great. Thank you very much for being with us today.

Dr. Alan Valentine: My pleasure.

Lisa Garvin: If you have questions about anything you've heard today, on Cancer Newsline, contact askMDAnderson at 1-877-MDA-6789 or online at [Background Music] Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.

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