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Management of Psychiatric Disorders in the Client with Cancer

Barbara Henry, MSN, APRN-BC

bjzh@aol.com

The overall goal of this session is to improve APRN competency with integrating psychosocial care and basic psychopharmacology prescription in oncology practice.

For More Information Try the ONS Webcourse:


Integrating Psychosocial Care into Oncology Practice
9.19 CNEs $99 for members $139 nonmembers 6 week self-paced online course Edited & facilitated by the ONS Psychosocial Education Team: Caryl Fulcher, Tracy Gosselin, Barb Henry, Tracy Kastenhuber, Laurl Matey, & Carol Tringali

Reproduced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Distress Management V.2.2013. 2013 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK, NCCN, NCCN GUIDELINES, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

Psychotropic Drug Classes


Oncology patients may be taking these types:
Antidepressants Anxiolytics (Anti-Anxiety) Mood Stabilizers Stimulants

Hypnotics (Sleep Agents) Antipsychotics


(Epocrates Online, 2013)

Erectile Dysfunction Drugs Smoking Cessation Drugs

Diagnosing Depression
Persistent low mood, loss of interest, anhedonia, reduced energy. In primary care, depression affects 5% to 30% of patients; estimates from 35%-80% of oncology patients. Risk factors-personal or family history of depression; recent stress, trauma, or loss; or have comorbid medical illness (cancer). Most patients respond well to psychotherapy, antidepressants, or a combination of both. Symptoms: weight change, libido changes, sleep disturbance, psychomotor problems, low energy, excessive guilt, poor concentration, suicidal ideation, grief reaction and substance abuse disorders may also be present.
(DSM V, 2013)

Case Study #1
A 35 y.o. married male seeks counseling/medication for depression. He is a fireman who underwent high dose chemotherapy for Hodgkins disease a year ago. His cancer is in remission, he is back to work, but frustrated that he is not physically/mentally what he was before the cancer and feels tired all the time. He tried Fluoxetine (Prozac)during chemotherapy which helped but made him feel a bit flat. He does not want sexual side effects and tried Buproprion (Welbutrin) which did not help his depression. He has no history of depression other than during chemotherapy.

What medication would you prescribe?


A. Methylphenidate (Ritalin) or another stimulant to help improve fatigue. B. Venlafaxine XR (Effexor) C. Vilazidone (Viibryd) D. Aripiprazole (Abilify)

Stimulants
Stimulants have been shown to improve fatigue in cancer patients and are sometimes used to augment antidepressant therapy as well as for attention deficit disorder.
Dextroamphetamine (Adderall)
Methylphenidate (Ritalin, Concerta, Daytrana- transdermal) Lisdexamfetamine (Vyvanse) Atomoxetine (Strattera) Modafinil (Nuvigil)-FDA approved for narcolepsy - dopamine reuptake inhibitor (Epocrates Online, 2013)

Dexmethylphenidate (Focalin)
Other ADHD drugs:

Stimulants for Cancer Fatigue Data


Fatigue - highly prevalent & distressing symptom associated with decreased quality of life among patients with cancer. Despite its impact on patients/caregivers, fatigue is underreported, underrecognized, & often untreated among patients with cancer because of various patient- and clinician-related factors. Among traditional psychostimulants, methylphenidate has been studied the most and is effective and well tolerated among patients with cancer despite common side effects. Modafinil, a novel psychostimulant-a wakefulness-promoting agents, has also been studied and well tolerated among patients with cancer. Randomized placebo-controlled trials with large sample sizes are needed to further assess the efficacy and tolerability of psychostimulants in the treatment of cancer-related fatigue because of a large placebo effect.

(Epocrates Online, 2013)

Antidepressants
Venlafaxine XR is a Selective Norepinephrine Reuptake Inhibitor (SNRI) like the drugs below. These drugs can be helpful for anxious depression or depression with low energy, but like all psychotropic medications, side effects and coming off these drugs may be difficult.

Venlafaxine (Effexor) 37.5, 75, 150 mg/day, maximum 300 mg/day Duloxetine (Cymbalta) 40-60 mg/day orally given as a single dose or in 2 divided doses Desvenlafaxine (Pristiq) 50 mg/day Milnacipran (Savella) 12.5-200 mg/day an SNRI approved in Europe to treat depression, FDA approved for fibromyalgia Bupropion hydrochloride (Wellbutrin) 150-300 mg/day, max 450 mg/day, can lower seizure threshold

(Epocrates Online, 2013)

Antidepressants
Venlafaxine XR is a Selective Norepinephrine Reuptake Inhibitor (SNRI) like the drugs below. These drugs can be helpful for anxious depression or depression with low energy, but like all psychotropic medications, side effects and coming off these drugs may be difficult.

Venlafaxine (Effexor) 37.5, 75, 150 mg/day, maximum 300 mg/day Duloxetine (Cymbalta) 40-60 mg/day orally given as a single dose or in 2 divided doses Desvenlafaxine (Pristiq) 50 mg/day Milnacipran (Savella) 12.5-200 mg/day an SNRI approved in Europe to treat depression, FDA approved for fibromyalgia Bupropion hydrochloride (Wellbutrin) 150-300 mg/day, max 450 mg/day, can lower seizure threshold

(Epocrates Online, 2013)

Antidepressants
Vilazadone is a Selective Serotonin Reuptake Inhibitor (SSRI) like the drugs below. These drugs can also be helpful for depression, some seem to be more calming, others more activating.

Citalopram (Celexa) 20-40 mg orally once daily Escitalopram (Lexapro)10-20 mg orally once daily Fluoxetine (Prozac) 20-60 mg orally once daily in the morning, doses >40 mg/day may be given in 2 divided doses Fluvoxamine (Luvox) 50-150 mg orally (immediate-release) twice daily Paroxetine (Paxil) 20-50 mg orally (regular-release) once daily Sertraline (Zoloft) 50-200 mg/day orally Vilazodone (Viibryd) 10 mg orally once daily for 7 days, increase dose gradually every week, maximum 40 mg/day Levomilnacipran (Fetzima) 20, 40, 80, or 120 mg/day, an SSRI FDA approved 7/26/13
(Epocrates Online, 2013)

2nd Generation Antipsychotics


Aripiprazole belongs to this class of drugs which are sometimes used to augment antidepressant therapy as well as to treat bipolar disorder and schizophrenia. There are many possible side effects and some of these drugs come in long acting injectables.
Aripiprazole (Abilify, Abilify Maintaina) Ziprasidone (Geodon) Lurasidone (Latuda) Olanzapine (Zyprexa, Relprevv)

Quetiapine (Seroquel)
Clozapine (Clozaril) Iloperidone (Fanapt) Paliperidone (Invega, Invega Sustenna) Risperidone (Risperdal, Risperdal Consta)

Asenepine (Saphris)

(Epocrates Online, 2013)

Which Drug Worked for Case Study #1?


Vilazodone (Viibryd) 10 mg orally once daily for 7 days, increase dose gradually every week, maximum 40 mg/day. The patient had tried an older SSRI (Fluoxetine) as well as an SNRI (Buproprion) although he had not tried any other psychotropic medications so I chose to try a new SSRI and it worked for this patient. General rules of thumb for prescribing psychotropic medications:
If the patient has had success with a medication in the past, it is logical to re-start that medication Psychotropic medications can take a couple weeks to work, some drugs/patients show improvement within the first week If a patient experiences a distressing side effect that does not go away within a few days, it is appropriate to try something else rather than insisting the patient continue the drug. (Epocrates Online, 2013)

Case Study #2
A 40 y.o. married female presents with depression/anxiety. She is on medical leave from her marketing job in order to treat her second recurrence of breast cancer now with lung metastasis. She takes 150 mg Venlafaxine XR, which helps depression/anxiety but she feels shaky/dizzy at times. She is very anxious with occasional panic and takes Clonazepam 1 mg bid though it takes 45 to work and then makes her feel tired (no history of substance abuse.) Her oncologist let her know that her type of disease will most likely cut her lifespan short, but she wants aggressive treatment since she has a 10 y.o. son & husband, a stay at home dad.

How would you manage the side effects from Venlafaxine XR and Clonazepam?
A. Decrease the Venlafaxine XR from 150 mg/day to 75 mg plus 37.5 mg (112 mg/day). B. Change Clonazepam to Buspirone or Hydroxazine. C. Change the Venlafaxine XR to Desvenlafaxine and change the Clonazepam to Alprazolam. D. Add Aripiprazole 2 mg/day to augment Venlafaxine XR.
(Epocrates Online, 2013)

Anxiety Treatment/Medications
for mild distress
Non-pharmacologic: Cognitive behavioral therapy (CBT), relaxation techniques, complementary integrative treatments; most effective is pharmacotherapy plus CBT/relaxation
1st line Hydroxyzine (Vistaril) is an option for patients not responding to psychotherapy that may be given on an "as required" basis if sedation is not problematic. Research shows some improvement in anxiety, with conflicting evidence of difference in efficacy compared to benzodiazepines. Somnolence, dizziness, and headache may limit its use. 50-100 mg orally four times daily/prn (25 mg for low weight or patients sensitive to medications) (Epocrates Online, 2013)

Anxiety Treatment/Medications
for moderate to severe distress
Selective serotonin-reuptake inhibitors (SSRIs) such as escitalopram. paroxetine, or sertraline; serotoninnorepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, or duloxetine, or buspirone. Buspirone (Buspar) effective in some patients and is also non-addictive; nausea or fatigue may limit its use. Recent benzodiazepine use is thought to reduce its efficacy. A tricyclic antidepressant (e.g., imipramine), secondgeneration antipsychotics (e.g., quetiapine/Seroquel), or pregabalin, (Lyrica) may be used, use of pregabalin is not recommended in patients with comorbid major depression.
(Epocrates Online, 2013)

Diagnosing PTSD/Anxiety in Oncology


PTSD is an anxiety disorder that may develop (either immediately or delayed) following exposure to a stressful event or situation of an exceptionally threatening or catastrophic nature (cancer diagnosis). In DSM-V re-categorized to its own class-Traumatic/Stress Illnesses

Anxiety prevalence in oncology patients (similar to depression), about 30%, most likely underreported; (PTSD is very prevalent in breast cancer survivors, although all types of cancer can re-trigger previous trauma/losses).
Characterized by 3 groups of symptoms: re-experiencing, avoidance, and hyper-arousal. Often comorbid with depression, anxiety, anger, and substance misuse. Other anxiety symptoms: excessive worry, muscle tension, sleep disturbance, fatigue, restlessness, irritability, poor concentration, panic attacks, shortness of breath/hyperventilation, heart palpitations, sweating, tingling sensations.
(DSM V, 2013)

Benzodiazepines
Alprazolam (Xanax) 0.25 to 0.5 mg orally (comes in immediate and extended-release) three times daily, maximum 4 mg/day (short acting) Lorazepam (Ativan) 0.25 to 0.5 mg orally (immediaterelease) three times daily, maximum 4 mg/day (midacting)

Clonazepam (Klonopin) 0.25 to 2 mg orally twice daily (long-acting) Diazepam (Valium) 2-10 mg orally two to four times daily (long-acting, not used as often)
(Epocrates Online, 2013)

Other Benzodiazepines
(used mainly for sleep)
Triazolam (Halcion) doses-0.125 mg/prn at hs, 0.25 and 0.5 max (short acting) Oxazepam (Serax) 10-15 mg tid/prn (short acting used occasionally for sleep, also for alcohol withdrawal) Estazolam (Prosom) 0.5 mg-2 mg prn/hs (mid acting)

Temazepam (Restoril) 15-30 mg prn/hs (mid acting)

Chlordiazepoxide (Librium) 5-10 mg up to tid/prn-used more for alcohol withdrawal (long-acting) Flurazepam (Dalmane) 15-30 mg prn/hs (long-acting)
Clorazepate (Tranxene) 15-30 mg q hs for anxiety (start with 7.5 mg bid, also used for alcohol withdrawal) (long-acting)
(Epocrates Online, 2013)

Which Medication Adjustment(s) Worked for Case Study #2?


Changing the Venlafaxine XR to Desvenlafaxine and changing the Clonazepam to Alprazolam. Desvenlafaxine (Pristiq) is a newer antidepressant that seems to have similar effects as Venlafaxine XR (Effexor XR) with fewer side effects, more convenient dosing and easier to discontinue (compared to Venlafaxine) if a different antidepressant is needed. Clonazepam is a long acting benzodiazepine that also takes longer to provide and effect, Alprazolam is a short acting benzodiazepine that works quicker for most. The patient in this case study is based on is now stable, on a less harsh chemotherapy regime and is much less anxious/depressed. She still has a limited lifespan but has dealt with end of life issues and has a better physical (and mental) quality of life now. She was on Alprazolam 1 mg tid, now 0.5 mg mainly at hs. (Epocrates Online, 2013)

Case Study #3
Client is a 56 y.o. married male with stage III renal cell cancer seen with his wife. He has moderate depression, severe insomnia, some paranoid & suicidal thoughts when most depressed. He takes St. Johns Wort-not helping. He took Ambien for sleep and it made him feel wired, had a harder time falling asleep & night eating that he didnt remember. He tried Sertraline in previous years that worked but he wanted to try natural remedies since his cancer. He also has erectile dysfunction for which Viagra works sometimes. His wife is supportive though very anxious herself. They work in therapy to maintain the best QOL as well as plan for future when client will no longer be with his family.

What psychotropic medication changes would you make?


A. Refer to Psychiatric APRN or Psychiatrist for more complex psychotropic medication management. B. Discontinue St. Johns Wort and start Sertraline, d/c Ambien add Risperidone 1 mg to 1 tab q hs. C. Consider Bipolar II Depression as a diagnosis rather than Major Depression. D. Offer Cialis to try instead of Viagra, provide samples.
(Epocrates Online, 2013)

St. Johns Wort


Effective for mild to moderate depression; alternative therapy (as mono therapy only) if there is no response to first- and second-line treatments.

Thought to work by inhibiting serotonin reuptake or decreasing cell surface serotonin receptors, same action as monoamine oxidase inhibitor (MAOI), the plant contains some Marplan, an MAOI.
Encouraging safety profile; however, may have clinically significant drugdrug interactions.

Must not be given concomitantly with other antidepressants due to the risk of serotonin syndrome.
Formulations may vary; refer to product literature for dosing guidelines, it is NOT FDA approved/regulated Same caution with Melatonin which may help with mild insomnia
(Epocrates Online, 2013)

Serotonin Syndrome
Clinical manifestation of excess serotonin in the CNS, resulting from the therapeutic use or overdose of serotonergic drugs. Characterized by a triad of clinical features: neuromuscular excitation, autonomic effects, and altered mental status. Neuroleptic malignant syndrome (NMS) bears some resemblance to serotonin syndrome, with similar symptoms of fever, mental status changes, and altered muscle tone. However, patients with NMS are usually akinetic with rigidity, have decreased levels of consciousness, and are more likely to have mutism rather than rambling speech, which is associated with serotonin toxicity. Both Serotonin Syndrome and NMS are fairly rare (anecdotally) no data available in the literature on incidence rates. Both conditions speak to the need for experienced psychiatric prescribers when complex psychotropic medication combinations are necessary.
(Epocrates Online, 2013)

Differential Diagnosis/Concerns for MDD, Biplar I, Bipolar II


MDD-Antidepressants, can augment with antipsychotics or stimulants. Bipolar I-Mood Stabilizers, antipsychotic medications usually Abilify, Seroquel, newer ones-Latuda & Saphris-very dangerous to use antidepressants with mood stabilizers since they may trigger mania/agitation/psychosis. Bipolar II-more depressive symptoms than manic symptoms though moods cycle, can respond to mood stabilizers and may also need antidepressants and/or antipsychotics.
(Epocrates Online, 2013)

2nd Generation Antipsychotics


Risperidone belongs to this class of drugs which are sometimes used to augment antidepressant therapy as well as to treat bipolar disorder and schizophrenia. There are many possible side effects and some of these drugs come in long acting injectables.
Aripiprazole (Abilify, Abilify Maintaina) Ziprasidone (Geodon) Lurasidone (Latuda) Olanzapine (Zyprexa, Relprevv)

Quetiapine (Seroquel)
Clozapine (Clozaril) Iloperidone (Fanapt) Paliperidone (Invega, Invega Sustenna) Risperidone (Risperdal, Risperdal Consta)

Asenepine (Saphris)

(Epocrates Online, 2013)

1st Generation Antipsychotics


Used less frequently than 2nd generation antipsychotics because of higher incidence of side effects, still used in chronic mental disorders when new drugs are less effective/patient is unwilling/unable to change. Chlorpromazine still used for hiccups and Prochlorperazine still used for nausea-make patients aware of possible side effects with these drugs.
Chlorpromazine (Thorazine) Prochlorperazine maleate (Compazine) Fluphenazine (Prolixin) Loxapine (Loxitane) Thioridizine (Mellaril) Thiothixine (Navane) Perphenzine (Trilafon) Haloperidol (Haldol) Trifluperazine (Stelazine)

(Epocrates Online, 2013)

Extrapyramidal Side Effects


Extrapyramidal symptoms (EPSs), such as akathisia, dystonia, psuedoparkinsonism, and dyskinesia, are drug-induced side effects of antipsychotic medications or other dopamine-blocking agents. EPS symptoms: atypical involuntary muscle contractions that influence gait, movement, and posture that can develop acutely or be delayed. Tardive dyskinesia is more permanent and may not be reversible even when the drug is stopped. TD symptoms: facial grimacing, finger movement, jaw swinging, repetitive chewing, tongue thrusting. Nurse practitioners who do not practice in psychiatric mental health nursing on a regular basis or who infrequently prescribe psychotropic medications must be cautious with these potential life-threatening symptoms. EPS has been reported with tricyclic antidepressants as well as some SSRIs and SNRIs.
(Epocrates Online, 2013)

Mood Stabilizing Medications


Aripiprazole (Abilify, Abilify Maintaina) Carbemazepine (Tegretol) Ziprasidone (Geodon) Valproic Acid (Depakote)

Lurasidone (Latuda)
Olanzapine (Zyprexa, Relprevv)

Quetiapine (Seroquel)
Lithium (Lithium Carbonate, Eskalith)

Oxycarbemazepine (Trileptal)
Lamotrigine (Lamictal)

Gabapentin (Neurontin)
(Epocrates Online, 2013)

What Worked for Case Study #3?


ALL OF THE ABOVE / BELOW

Referred to Psychiatric APRN for more complex psychotropic medication management (and couples counseling) D/cd St. Johns Wort and started Sertraline; d/cd Ambien and added Risperidone 1 mg to 1 tab q hs He responded to the augmentation of Zoloft with Risperidone, could have Major Depression more likely Bipolar II since there was a touch of hypomania. Cialis restored sexual functioning and we had samples.
(Epocrates Online, 2013)

Thanks for your attention