Canterbury DHB
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Anxiety symptoms are common in people with cancer. The presence of these may not necessarily present a clinical problem, and in many could be considered part of a ‘normal’ reaction. However, the rate of diagnostically-significant anxiety disorders ranges from 10-30%.
Clinically significant disorders likely to arise include panic disorder, adjustment disorders, phobic disorders, and conditioned responses such as anticipatory nausea.
As with depression (see below), the applicability of traditional diagnostic criteria is complicated by cancer symptoms and treatment.
Duration of symptoms is usually important in distinguishing between normal anxiety in the face of a threat, and clinically significant anxiety.
Level of functional disruption is another dimension to consider. Highly disrupted concentration, psychomotor agitation, impaired social functioning, and other activities of daily living should be appraised, along with avoidance and checking behaviours, or evidence of seeking excessive reassurance.
Anxiety can often co-occur with depression, and treatment of this latter condition can dramatically improve anxiety.
A range of psychological and pharmacological treatments have been found to be relatively effective in cancer patients with anxiety disorders.
Unless urgency dictates otherwise, referral for a fuller assessment of symptoms and diagnostic work-up can be made to the Clinical Psychologists (email) in the first instance. A brief written referral is preferred (especially for Haematology Outpatients), although verbal referrals in the context of ward rounds/reviews are acceptable. More specialised reviews by others (e.g. Psychiatrists) will be arranged where requested or indicated. Cover for referrals (in hours) is provided by the Psychiatric Consultation-Liaison Service (ph 3638-100). Psychiatric emergencies out-of-hours should be referred to the on-call Psychiatric Emergency Service (3640-482).
Where drug treatment is being considered, several drugs can be used to treat anxiety in patients with cancer, although again there is little systematic evidence as to what is effective. The following medications might be considered.
Tricyclic antidepressants (most evidence is for imipramine and clomipramine) have been shown to be beneficial in non-medical patients. The anxiolytic effect is slow in onset. These drugs have anticholinergic, antihistaminic, sedative, and hypotensive side effects. However, they are not dependency-inducing and are obviously particularly useful if there is depression associated with the anxiety.
Less evidence of benefit; certainly consistent suggestions that these drugs are useful. They have fewer anticholinergic side effects than TCAs. Also have some time for onset and may initially increase anxiety, so should be started at a low dose and gradually titrated upward. Often quite high doses (e.g. 60 mg) are needed to effectively treat anxiety.
Benzodiazepines' effectiveness and relative lack of toxicity are well established. They have a rapid onset of action and are generally well tolerated by patients. All benzodiazepines can induce dependency. The risk of dependency in anxious patients may have been exaggerated. Less sedative and slightly longer-acting benzodiazepines, alprazolam and clonazepam are currently favoured.
Their benefits are unproved in randomised control trials. They may be a useful adjunct to benzodiazepines and are not dependency-inducing. Risks of acute extrapyramidal side effects for the older antipsychotics and the possibility in the long term of tardive dyskinesia. Newer antipsychotics, particularly quetiapine, are being increasingly used despite the lack of any systematic evidence that they are useful.
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Topic Code: 5048
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