Luigi Grassi

Psychological Factors Affecting Oncology Conditions

The area of psychological factors affecting cancer has been the object of research starting from the early 1950s and consolidating from the 1970s with the development of psychooncology. A series of problems in the DSM and ICD nosological systems, such as the difficult application of the criteria for psychiatric diagnoses (i.e. major depression, adjustment disorders) and the scarce space dedicated to the rubric of psychosocial implications of medical illness (i.e. Psychological Factors Affecting a Medical Condition under Other Conditions That May Be a Focus of Clinical Attention in the DSM-IV) represent a major challenge in psycho-oncology. The application of the Diagnostic Criteria for Psychosomatic Research (DCPR) has been shown to be useful in a more precise identification of several psychological domains in patients with cancer. The DCPR dimensions of health anxiety, demoralization and alexithymia have been shown to be quite frequent in cancer patient (37.7, 28.8 and 26%, respectively). The overlap between a formal DSM-IV diagnosis and the DCPR is low, with 58% of patients being categorized as non-cases on the DSM-IV having at least one DCPR syndrome. The specific quality of the DCPR in characterizing psychosocial aspects secondary to cancer is also confirmed by the fact that some dimensions of coping (e.g. Mini-Mental Adjustment to Cancer subscale hopelessness) correlate with the DCPR dimension of demoralization, while a quantitative approach on symptom assessment (e.g. stress symptoms on the Brief Symptom Inventory) is not useful in discriminating the patients with and without DCPR syndromes. More research is needed in order to understand the relationship between DCPR constructs (e.g. alexithymia) and psychosocial factors which have been shown to be significant in oncology (e.g. emotional repression and avoidance). The role of specific DCPR constructs in influencing the course of illness is also an area that should be investigated.

Clinical Psycho-Oncology: An International Perspective

List of Contributors, vii Foreword, xi Acknowledgements, xiii Part 1 Clinical Issues 1 Introducing Multicultural Psycho-oncology, 3 Luigi Grassi and Michelle Riba 2 Communication in Cancer Care: A Cultural Perspective, 11 Phyllis Butow and Walter F. Baile 3 Psychosocial Assessment and Screening in Psycho-oncology, 21 Paul B. Jacobsen and Kristine A. Donovan 4 Sexuality and Gender: Psychosocial Implications in Cancer Patients: A Multicultural Perspective, 39 Anna Costantini, Chiara M. Navarra, Kimlin Tam Ashing-Giwa and Sophia Yeung 5 Psychosocial and Psychiatric Disorders, 55 Santosh K. Chaturvedi and Yosuke Uchitomi 6 Neurocognitive Effects of Anticancer Treatments, 71 Tim Ahles, Sanne Schagen and Janette Vardy 7 Screening for Distress, the 6th Vital Sign, as the Connective Tissue of Health Care Systems: A Roadmap to Integrated Interdisciplinary Person-centred Care, 83 Barry D. Bultz, Matthew J. Loscalzo and Karen L. Clark 8 Psychological Intervention, 97 Maggie Watson 9 Psychopharmacological Interventions, 109 Seema M. Thekdi, Marya Elisa Irarrazaval and Laura B. Dunn 10 Rehabilitation, 127 Anja Mehnert and Uwe Koch Part 2 Special Populations 11 Pediatric Psycho-oncology, 139 Margaret L. Stuber and Elizabeth M. Strom 12 A Life-stage Approach to Psycho-oncology, 155 Peter Fitzgerald, Rinat Nissim and Gary Rodin 13 Psycho-oncology in Underserved and Minority Populations, 165 Richard Fielding and Wendy W.T. Lam Part 3 Other Topics 14 Exploration of Family Care: A Multicultural Approach, 187 Lea Baider and Gil Goldzweig 15 Bioethical Challenges: Understanding Cultural Differences and Reducing Health Disparities, 199 Antonella Surbone 16 Post-traumatic Growth in Cancer Patients Across Cultures, 211 Michael Diaz, Matthew Cordova and David Spiegel 17 The Need for Psychosocial Support in Genetic Counselling and Genetic Testing, 223 Mary Jane Esplen, Jonathan Hunter and Kathryn M. Kash 18 Psychosocial and Physical Health in Post-treatment and Extended Cancer Survivorship, 237 Patricia A. Ganz and Annette L. Stanton 19 End-of-life Care, 249 William Breitbart, Harvey Max Chochinov and Yesne Alici 20 Grief and Bereavement, 271 Sue Morris and Susan Block 21 Spiritual and Religious Coping with Cancer, 281 David W. Kissane, Carrie E. Lethborg and Brian Kelly 22 Psycho-oncology and Advocacy in Cancer Care: An International Perspective, 297 Luzia Travado, Jan Geissler, Kim Thiboldeaux, Jeff Dunn, Ranjit Kaur and Anne Merriman Index, 311

Communication with Patients Suffering from Serious Physical Illness

Communication is the corner stone of the relationship with the patient in all medical settings with the main aims of creating a good inter-personal relationship, exchanging information, and making treatment-related decisions. In a rapidly changing cultural and social context, the paternalistic approach of doctors knowing the best and deciding what should be done for a patient has been replaced by a shared decision-making approach, with patients being advised to educate themselves, ask questions and influence the course of the discussion with their doctors. Thus, a need for an improvement in the communication skills of physicians is extremely important for patients affected by serious physical illness (e.g. cancer, HIV infection, multiple sclerosis, amyotrophic lateral sclerosis). Certain attitudes, behaviour and skills (e.g. capacity to impart confidence, being empathetic, providing a human touch, relating on a personal level, being forthright, being respectful, and being thorough) are part of effective communication. However, some specific aspects influencing doctor-patient communication and relationships, such as personality variables, coping and attachment styles, as well as cultural factors, should also be taken in to account. The development of training curricula to help doctors acquire proper skills in communication is mandatory, since research has shown that training in communication may facilitate the effectiveness of a doctor-patient relationship and the patients satisfaction with care and give a general sense of humanity, which is easily lost in a biotechnologically oriented medicine.

Pharmacotherapy of Depression in Cancer Patients

Pharmacotherapy is an important component of treatment for more severe and persistent depression in patients with cancer and advanced disease. The initiation of such treatment should follow a careful diagnostic assessment, and the choice of an antidepressant should be based upon the symptom profile of the patient, the antidepressant side-effect profile, and the least potential for interaction with chemotherapy and other medications. Although an antidepressant medication with a rapid onset of action is desirable in this population, psychostimulants and other such agents have not been shown to be effective. Psychotherapy should typically be provided in conjunction with pharmacotherapy and, in the case of minor depression, may be the sole therapeutic modality. This includes attentive psychoeducation on common concerns about antidepressants expressed by medical patients, in order to ensure safety and enhance compliance.

Interpersonal Relationship Issues in Psychopharmacology

Communication is the essential component for good clinical practice within a patient-centered approach, with guidelines empathizing the role of communication and the mandatory need to train physicians in communication in order to assure optimal psychosocial care of cancer patients, including the psychosocial interview patient assessment, prescription, and follow-up. The aim of this chapter is to briefly summarize some principles of communication when dealing with cancer patients with psychiatric disorders in order to facilitate assessment and promote adherence to treatment and to suggest guidelines which the clinician may use to achieve these goals. For these reasons, the protocol SPIKES-Rx has been specifically developed to guide doctors in the appropriate interactions to promote patient agreement with recommendations for psychopharmacological management when psychotropic drugs are prescribed.