Donna B. Greenberg

Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association

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Fatigue syndrome due to localized radiation

For cancer patients, fatigue is a disturbing symptom caused by many factors. Since fatigue is the most common side effect of localized radiation to the breast, this treatment provides a unique opportunity to follow patients prospectively as they develop one type of fatigue. We evaluated the effect of radiation treatment in 15 women with Stage I or II node-negative breast cancer who were otherwise healthy. Fatigue, contrary to our hypothesis, did not increase linearly with cumulative radiation dose over time. It dropped from the first to second week and rose in the third week. The cumulative effects reached a plateau in the fourth week (after an average of 17 fractions), which was maintained during the remaining weeks of treatment. Within 3 wk after treatment, fatigue had diminished. No patient had sustained depressive symptoms. Cardiopulmonary exercise capacity in 5 patients at 6 and 12 wk did not change from just before radiation. Other markers, including reverse triiodothyronine and pulse change with orthostatic stress, did not correlate with subjective fatigue nor cumulative radiation in 15 patients. The curve of the fatigue syndrome during treatment conforms to the adaptation of the organism to a continuing stress and begins to describe a mild fatigue syndrome associated with radiation.

Treatment-related fatigue and serum interleukin-1 levels in patients during external beam irradiation for prostate cancer

To define changes in sleep and subjective fatigue associated with localized radiation treatment, and to determine their relationship to interleukin-1B (IL-1), we prospectively followed 15 men, none of whom were depressed during 8 wk of radiation treatment for localized prostate cancer. Each patient rated fatigue daily on a visual analogue scale, recorded hours slept, and completed the Beck Depression Inventory weekly. Serum IL-1, taken at baseline and Fridays, was measured by quantitative enzyme immunoassay. Ranked weekly mean fatigue scores for each subject increased at week 4 (mean, 17 fractions, 1.8 Gy) then plateaued and rose in weeks 6 and 7. In week 6, the last week of full volume radiation, subjects slept most compared to all other weeks including week 7 when treatment was coned down. Ranked serum IL-1 tended to rise between weeks 1 and 4, as fatigue scores rose. These data suggest that localized radiation treatment is associated with increased fatigue and sleep requirement independent of depressive symptoms. Relative serum IL-1 changes may be one signal for the systemic reaction and subjective fatigue associated with the acute effects of radiation.

Neurasthenia in the 1980s: Chronic Mononucleosis, Chronic Fatigue Syndrome, and Anxiety and Depressive Disorders

In the 1980s, patients suffering from unexplained fatigue and what seemed like a prolonged attack of acute mononucleosis were given the diagnosis of chronic mononucleosis or chronic infection with the Epstein-Barr virus. Although the diagnosis has great appeal, the Epstein-Barr virus does not cause the syndrome (CFS) of chronic fatigue, which has been renamed and redefined chronic fatigue syndrome to remove the inference that the virus is its cause. From a historical perspective, both syndromes represent the 1980s equivalent of neurasthenia, a disease of fatigue that influenced the development of psychiatric nosology. Because patients with depression and anxiety also have chronic fatigue and because most patients with CFS have an affective disorder, the assessment of organic causes of this syndrome requires careful psychiatric diagnosis and treatment. Defining chronic fatigue syndrome as a medical disorder may deprive patients of competent treatment of their affective disorder.

Adjuvant therapy of melanoma with interferon-alpha-2b is associated with mania and bipolar syndromes: Gabapentin may serve as a mood stabilizer

The use of a high dose regimen of interferon‐alpha‐2b (IFN) has recently been demonstrated to benefit patients with resected high risk melanoma. The incidence of melanoma is rising rapidly, and the use of this regimen is becoming increasingly common. IFN has been associated with numerous psychiatric side effects.

Iatrogenic acute estrogen deficiency and psychiatric syndromes in breast cancer patients.

The change of estrogen function, represented by amenorrhea or hot flashes, that results from breast cancer treatment may increase the risk of major depressive disorder in those women undergoing treatment for breast cancer. This pilot study describes the course of menopausal symptoms and the incidence of depression in 21 patients who were likely to become acutely estrogen deficient during treatment for breast cancer. These included women who lost menses during chemotherapy, who suddenly stopped estrogen replacement therapy (ERT), or who started tamoxifen. Eight patients (38%) developed major depressive disorder, the majority within 6 months of starting treatment. Twenty patients (95%) had dysphoria and/or insomnia. Fourteen patients (66%) had hot flashes. While this is only pilot data, these data suggest that breast cancer patients whose treatment precipitates menopausal symptoms should be targeted for diagnosis of depression and treated if diagnosed.

Neuropsychiatric presentation of men with pituitary tumors (the ‘four A's’)

Abstract A chart review of 16 male patients with prolactin-secreting pituitary adenomas revealed the frequent presence of four neuropsychiatric signs and symptoms: apathy, asexuality, adiposity, and (head)ache. This symptom constellation can be easily mistaken for that of an affective disorder. Male patients displaying these four signs and symptoms should be referred for an endocrinologie consultation. A case report further illustrates the clinical picture.

The Measurement of Sexual Dysfunction in Cancer Patients

THE STUDY OF SEXUAL DYSFUNCTION in cancer patients requires putting sex in perspective. In the past, inhibited patients did not ask for information about sexual function, and inhibited doctors did not offer information to patients who did not ask. Yet most people would agree that men feel more like men and women more like women when they know they have the capacity for sexual interaction. In fact, libido signifies life energy as opposed to the apathy, asthenia, and abandonment that people fear with progressive cancer. Even so, the value of sexual function must be measured in the personal context of the patient. Is a patient dysfunctional who does not define himself that way? If the threat to life makes sex a secondary issue, is sexual function abnormal? In patients who have had a benign hysterectomy, more recent researchers, who looked more compulsively for sexual problems, found higher frequencies of sexual dysfunction. 1 The percentage of patients with sexual dysfunction correlated with the year that the study was done. Over these years evaluation of sexual function has become more fashionable and less taboo, but the newer studies do not necessarily reflect more accurately the significant loss to patients. Women who had pelvic surgery for cancer were found 6 months later to have made an excellent social adjustment, re-establishing a sense of general well-being and self-esteem. 2 This social adjustment occurred in spite of acknowledged change in body image and impaired sexual function. These data fit with a study of cancer patients who experienced simultaneously with their spouses an increase in desire for physical closeness and a decrease in the desire for sexual intercourse. In addition to the severity of illness, the patients premorbid sexual experience, developmental stage, expectations, relationships, and age affect his or her definition of loss.

Management of Lithium in Patients With Cancer

This article reviews the management of lithium in patients who require optimum management of cancer and simultaneous prevention of mania or depression in lithium-sensitive affective illness. Two cases are described. Discussion focuses on whether lithium should be continued during chemotherapy and radiation treatment, the complications that would lead to lithium toxicity in an otherwise stable patient, the likely settings for hypothyroidism, and the role of lithium to stabilize steroid-induced affective changes. The authors conclude that lithium may be withheld 1 or 2 days before cytotoxic chemotherapy and restarted when the patient is able to drink. It may be given as usual through routine radiation treatment, but it should be discontinued during cranial radiation. Calcium, renal, cardiac, and thyroid functions should be monitored.

Psychosocial Training in a Palliative Care Fellowship

We present a description of a one-year palliative care fellowship training program for physicians at the Massachusetts General Hospital. We provide background information on the Palliative Care Service, and offer an overview of the educational content and methods for fellowship training, focusing especially on psychosocial aspects of care. The medical background and post-training positions of fellows are described. This document is meant to assist other palliative care fellowship programs in developing their curricula and possibly to serve as an initial template for creating educational standards and for identifying outcome measures for educational evaluation of such programs.