Cancer patients and survivors are increasingly being diagnosed with depression
Depression, anxiety and fear are fairly common mental health issues among persons with cancer. Poornima BV of White Swan Foundation spoke to Dr M N Sundareshan, consultant psychiatrist, Rangadore Memorial Hospital, who stresses on the need to deal with the mental health aspects of cancer care.
As a psychiatrist working with persons who have cancer, what has been your experience in dealing with their mental health concerns?
Persons with cancer come in with a lot of mental health issues like depression, anxiety, fear, psychosis, and body image issues. Many among them come in with symptoms of depression. This issue is dealt with minimally - or not at all - by the treating specialist due to lack of awareness about mental illness, or due to lack of time. This is unacceptable.
All these conditions can be easily treated if the patient consults with a qualified psychiatrist who can offer them mental health support and treatment. It must be stressed here that treatment of both the body and the mind is more important than treating only the body or the mind.
Can dealing with the mental health aspects of cancer help in fighting the disease itself?
There's a direct correlation between mental wellbeing and increased body immunity. In fact, it's well-established that when the patient's immunity improves, their ability to fight the disease also improves. This will, in turn, complement the treatment they are receiving for the primary disease itself. I must stress here that depression can be treated. It's well-established after several years of study - especially among persons with breast cancer – that treating psychological morbidity improves the immunity and reaction to specific drugs and treatment. Almost all persons diagnosed with cancer and their caregivers must be reviewed first by a psycho-oncologist.
In your experience, have you found that people are open to consulting a psychiatrist when they are diagnosed with cancer?
A fair number of people who visit hospitals, including their relatives and caregivers, do not visit psychiatrists. In the Western countries, almost all persons with cancer go to psycho-oncologists to deal with the mental health component for assessment and treatment. There's an urgent need to provide support and care for the person with cancer, as well as their caregiver. The sooner they get mental health support, the better it would be for them. After proper assessment and treatment by a psychiatrist, their quality of life improves, as does their longevity.
In India, there's a lack of training and awareness regarding mental health, even among medical professionals. In all communities – both educated and the not so educated – there's fear, stigma and ignorance regarding mental health issues. There's a total lack of awareness regarding mental health management and its benefits in our country as a whole due to poor education in this field and severe shortage of the required manpower
When they do come in, what are their thoughts, worries and anxieties?
Many of them come in because they are forced to come by their relatives or caregivers – they experience great fear, non-specific physical pain – they have fatigue, mood swings, helplessness, poor or increased sleep, guilt, lethargy and minimal interest in everyday routine activities. They come in with poor social and personal functioning. They also have morbid feelings - they say that they are better off dead than alive.
After treatment for cancer, some of them come with psychosis and unjustified fear that the doctors are taking away their body parts. Some of them are addicted to alcohol due to fear and anxiety.
How important is it to involve the family when offering psychological support?
It's very important that individual caregivers are properly educated about how they can support the person and identify early warning symptoms before the onset of depression and learn about managing them themselves to some extent before they can reach a mental health professional.
It's of utmost importance to offer support, education and to treat the caregivers - as they do a lot more to help them at the expense of their own quality of life (social, physical and financial). Without adequate support, the caregivers may adapt maladaptive behaviour, denial and neglect, sometimes falling back on drinking as a coping mechanism, leading to their own ill health. In such cases, it's the family and caregivers who need to be supported.
Sometimes, or is it always, that the mental health needs of a person with cancer has to be addressed first, even before the treatment for cancer itself begins?
Diagnosis of cancer must always be followed by mental health assessment of both the person with cancer and the caregiver. There are protocols to this effect – a simple form with a list of questions and answers can be used to assess the mental health components. A nurse can perform this task. Once the mental health component is assessed, the information can be passed on to a mental health specialist for a deeper diagnosis and understanding. Unfortunately, these protocols are not being followed, although these protocols do exist. Oncologists dealing with cancer have no time or interest to refer these patients to mental health professionals – these assessments are a must in cancer hospitals.
Does cancer itself predispose someone to depression?
Yes, specific types of cancer – ovarian cancer, breast cancer, testicular cancer and some others have endocrinal effect, leading to mental illness, especially depression. Cancer treatment – surgery, medications, radiation – these are known to cause mental illness of various types and degrees during and after the treatment. These and other side effects have to be made aware even before the treatment is started. Persons with cancer and their caregivers should demand to know this from doctors before acceptance of treatment.
What about women and cancer? Especially with the increased prevalence of breast cancer?
Although it's the most known cancer, early detection of breast cancer has been of great help (with self examination and appropriate treatment options). However, due to negligence and guilt and inappropriate diagnosis some women come to cancer specialists late in life - this leads to a lot of social and personal complications and maladaptive behavior. In some cases, women with breast cancer come with a sense of having lost their identity as women. These concerns have to be first addressed. Sometimes there are social implications leading to affairs, divorces and many other complications and consequences. All these issues do have an impact on their mental health condition.
Also, it's unfortunate that the men who accompany women talk about the illness without allowing these women an opportunity to express themselves.
Does psychological support prevent cancer progression?
It is a well established fact that psychological intervention and support to persons with cancer has proved to be effective in improving the quality of life and longevity. Those with poor psychological support and undiagnosed physical illness have a poor quality of life and increased morbidity. They are known to later develop maladaptive behavior, leading to poor prognosis and poor response to medications.
Can they withstand pain better when they are better equipped mentally?
Yes, they can definitely manage their physical and mental pain - improve the quality of life and longevity- if they are aware, educated and appropriately treated for the mental health component of the illness. Once that is addressed, both the person with cancer and the caregiver become are better equipped to deal with the situation.
What would your advice be as a psychiatrist to persons with cancer?
I would say don't lose hope. Ask for help. Depression as a mental health component is easily treatable and can improve the quality of life significantly. Also, the response to cancer treatment would be much better with mental health support. It's your right to demand this treatment. It's your right to be fully aware of the illness, treatment and the complications arising out of it. Make up your mind about the treatment after getting all the associated medical information. Don't be pushed to take treatment or refuse treatment without knowledge or out of fear. Each and every person with cancer and their caregiver should be provided with this knowledge.