Even the country’s premier cancer hospitals, like Bharatpur and Bhaktapur cancer hospitals, don’t provide formal psychiatric services to cancer patients. And while palliative-care psychiatry is a well established sub-specialty worldwide, here, the burden of mental disorders arising from cancer have to be borne by the patients themselves.  Stakeholders and the general public in our country still find it hard to grapple with the fact that in terminal illnesses like cancer, psychiatric co-morbidities plays an even greater role in overall management, treatment compliance, course and prognosis of the disease.

Mental disorders common in cancer patients

Research has shown that nearly half of the cancer patients also suffer from additional diagnosable mental disorders, which need expert psychiatric intervention. And although cancer is a physical illness, nearly 50 percent of the top 16 symptoms are psychological. Apart from the fear and pain caused by the disease itself, treatment procedures (chemotherapy, radiotherapy, surgeries, etc) and environment also have a role to play in causing these disorders.

The common psychiatric disorders associated with cancer are: adjustment disorder; depressive disorder; delirium, dementia and other cognitive disorders; personality disorder; schizophrenia and other psychotic disorders; bipolar disorder; substance-abuse disorder; and somatoform disorder.

Cancer and pain

The most common (nearly 50-75 percent in advanced cases) and one of the most distressing symptoms of cancer is pain. More than half of the cancer patients suffer from moderate to severe pain and the remaining 20-30 percent have excruciating pain. To make matters worse, nearly one-third of these patients do not respond to conventional painkillers. Some studies have shown that the reason behind the inefficacy of these painkillers could be psychological in nature, since emotional reactions result form and contribute to the experience of pain.

Cancer and suicide

Nearly 10 percent of people suffering from terminal illnesses, including cancer, die by committing suicide, while many more harbour the thought of committing one. Hence, it is very important that every cancer patient be carefully evaluated by mental-health experts. Depression, hopelessness, poorly controlled pain, delirium, a feeling of loss of control, exhaustion, anxiety, substance-abuse disorder and prior attempts as well as family history of suicide attempts are all significant risk factors which require careful monitoring.

Ethical issues in cancer

Cancer management pushes healthcare professionals to think about not only the technical/ financial issues surrounding the disease, but also the ethical ones. Issues like truth-telling (which entails that patients honestly disclose all the necessary information), getting informed consent of patients for certain procedures, patients’ right to refuse treatment and euthanasia (mercy killing) cannot be dealt with legislative measures only. These issues require the intervention of mental-health professionals who can make psychological assessments of the patients and decide what is best for them.

Conclusion

Since Nepal suffers from a chronic lack of skilled manpower in the mental-health sector, finding psychiatrists for every cancer patient is an unattainable goal. So we could perhaps start training primary physicians to render basic psychiatric services to these patients while making them refer complicated medical cases to psychiatrists.  

As I have mentioned above, the stakeholders in our country are either totally unaware or irresponsibly negligent of the psychological problems that cancer entails. We need to start providing an integrated service to the patients and their families.

Of course, it would be better if the Ministry of Health came up with long-term national directives regarding hospice and palliative care for terminally ill patients, but until then we require individual awareness and grass-root efforts to deal with these problems.

Dr Shakya is the Assoc Professor and Head of the Department of Psychiatry at the Patan Academy of Health Sciences