MIAMI – Serious psychiatric comorbidities should not deprive cancer patients of life-salvaging or life-enriching therapies, according to two psychiatrists who have helped such patients to achieve successful outcomes with treatment for their physical and mental disorders.
Aggressive psychiatric treatment preserved patients’ eligibility for bone marrow transplantation (BMT) and allowed terminally ill patients to "participate in the important process of saying goodbye," the clinicians reported during separate presentations at the annual meeting of the American Psychosocial Oncology Society.
Bone Marrow Transplantation Feasible
Dr. Isabel Schuermeyer, director of psycho-oncology at the Cleveland Clinic, underscored her contention that even suicidal ideation should not, in most cases, be a contraindication for BMT. She described the case of a 55-year-old mantle cell lymphoma patient with a lengthy history of depression who developed myelodysplastic syndrome following an initial autologous BMT.
"I think there should be no psychiatric contraindication to BMT."
While under consideration for repeat BMT, he developed suicidal ideation, including formulating a plan to drive a car into a wall or poison himself with carbon monoxide. Intensive, collaborative management and a brief inpatient psychiatry admission combined to stabilize the patient on mirtazapine (Remeron) and clonazepam within 2 weeks, she reported. Although rapidly progressive medical complications precluded a second BMT, his psychiatric condition became stable.
A second psychiatric intervention involved a 57-year-old woman with multiple myeloma who drove 1,000 miles without stopping, just to make an appointment at the Cleveland Clinic. This followed her firing of four oncologists in 6 months in her city of origin. Relevant history included an early suicide attempt, alcohol abuse, and anxiety.
On examination, the patient exhibited racing thoughts, a diminished need for sleep, and excessive activity and distractibility. With close follow-up by the psychosocial oncology team and initiation of quetiapine (Seroquel) therapy, the patient’s hypomanic symptoms soon abated, and she was able to safely undergo a transplant.
"She actually did really well and had some insight," Dr. Schuermeyer said in an interview. "She was sleeping 8-9 hours a night."
The literature on psychiatric suitability for BMT is sparse, she noted. In 2006, Foster and colleagues reported (Bone Marrow Transplant. 2006:37:223-8) that nearly 90% of BMT professionals would not transplant a patient with suicidal ideation.
A small case series (Psychiatry Clin. Neurosci. 2003:57:311-5) reported that six of seven patients with psychiatric illnesses were able to undergo BMT with the exception of one patient with borderline personality disorder.
There is a widespread belief that patients with a psychiatric history may not be good candidates for BMT due to concerns about adherence, Dr. Schuermeyer noted. "Everyone wants great outcomes with BMT," she said in an interview.
However, her belief, grounded in experience, is that close collaboration and competent mental health care can overcome psychiatric obstacles in the vast majority of cases. "I think there should be no psychiatric contraindication to BMT. At the end of the day, this is a lifesaving treatment," she said.
Unlike in solid organ transplantation, years of compliance are not required. "Let’s just save peoples’ lives. Let’s be aggressive and work together as a team," she said.
Depression Eased by ECT
Dr. Carlos G. Fernandez-Robles of the psychiatry oncology service at the Massachusetts General Hospital Cancer Center in Boston advocated aggressive treatment of another sort. Using three clinical cases as examples, he outlined the effective use of electroconvulsive therapy in cancer patients with profound treatment-resistant depression that included catatonic symptoms.
Catatonia, he said, is an uncommon entity in general, and even more so in cancer patients; it is likely often unrecognized, however, and can be a manifestation of paraneoplastic encephalopathy, CNS chemotherapy toxicity, or psychiatric in origin.
In one such patient, a 40-year-woman with unresectable T4bN2cM0 maxillary adenoid cystic carcinoma treated with radiation and combination chemotherapy, was admitted to the hospital for failure to thrive, weight loss, and immobility. On examination, she demonstrated mutism, posturing, limb rigidity and mild waxy flexibility, gegenhalten hypertonia, and grasp reflex.
While lorazepam (Ativan) 2 mg IV temporarily resolved her symptoms, the team was unable to achieve any sustained response to psychopharmacologic treatment. The patient responded fully to six treatments with electroconvulsive therapy and was able to complete radiation and chemotherapy, Dr. Fernandez-Robles said.
A second patient with profound depression had complete response to six rounds of ECT after he failed to respond to a variety of medications following resection of right temporal lesions and an anterior temporal lobectomy for multicentric glioblastoma multiforme.
Very few studies have been published of ECT in cancer patients, in large measure because of a stigma not only among members of the general public, but in medical training as well, Dr. Fernandez-Robles said.