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Management of psychiatric disorders in patients with cancer

Peter P Roy-Byrne, MD
Section Editor
Jonathan M Silver, MD
Deputy Editor
David Solomon, MD


Patients with cancer have a high rate of psychiatric comorbidity; approximately one-half exhibit emotional difficulties. The psychological complications generally take the form of adjustment disorder, depressed mood, anxiety, impoverished life satisfaction, or loss of self-esteem. The patients most at risk for depression and other psychiatric illness have advanced disease, a prior psychiatric history, poorly controlled pain, and other life stressors or losses.

In addition to these psychiatric conditions, non-specific distress and anxiety are very common in cancer patients, in addition to formal psychiatric diagnoses. Distress is the summation of multiple psychological, social, and spiritual factors. If severe enough, distress can interfere with the patient's ability to deal effectively with the illness, its symptoms, and the complications of treatment.

Specific issues regarding the management of psychiatric illness in patients with cancer are reviewed here. The diagnosis of these disorders is discussed separately. (See "Diagnosis of psychiatric disorders in patients with cancer".)


The identification and diagnosis of adjustment disorder is not straightforward, but is important since many of these patients will benefit from counseling. Physicians attempting to identify individuals who could benefit from counseling should focus upon a lack of patient flexibility [1,2]. Those who develop adjustment disorder may be more rigid in their thinking and determined to address their cancer-related problems in the same manner as they have for prior stressors. If the old coping and problem-solving strategies fail, the person may begin to exhibit depressed mood and anxiety associated with adjustment disorder. In contrast, patients who successfully adapt typically have a flexible style [3].

People with adjustment disorder have positive outcomes when they are treated with brief psychotherapy [4]. Early treatment using counselors, nurses, and other staff is helpful before the problem expands to the point of requiring more intensive care.

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Literature review current through: Nov 2017. | This topic last updated: Mar 21, 2017.
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  1. Carson DK, Council JR, Volk MA. Temperament as a predictor of psychological adjustment in female adult incest victims. J Clin Psychol 1989; 45:330.
  2. Rogers S, LeUnes A. A psychometric and behavioral comparison of delinquents who were abused as children with their non-abused peers. J Clin Psychol 1979; 35:470.
  3. Lee RE. Returning to work: potential problems for mid-career mothers. J Sex Marital Ther 1983; 9:219.
  4. Sifneos, P. Brief dynamic and crisis therapy. In: Comprehensive Textbook of Psychiatry, vol. 2, 5th ed, Kaplan, H, Sadock, B (Eds), Williams and Wilkins, Baltimore 1989. p.1562.
  5. Pollin IS. Model curriculum in Medical Crisis Counseling. Linda Pollin Foundation/NIMH Workshop. Gen Hosp Psychiatry 1992; 14:11S.
  6. Wise, M. Adjustment disorders and impulse disorders not otherwise classified. In: The American Psychiatric Press Textbook of Psychiatry, 2nd ed, Talbot, J, Hales, R, Yudofsky, S (Eds), American Psychiatric Press, Washington, DC 1994.
  7. Spiegel D, Bloom JR, Yalom I. Group support for patients with metastatic cancer. A randomized outcome study. Arch Gen Psychiatry 1981; 38:527.
  8. Zabora, J. Screening procedures for psychosocial distress. In: Psycho-oncology, Holland, J (Ed), Oxford University Press, New York 1998. p.653.
  9. Lydiatt WM, Bessette D, Schmid KK, et al. Prevention of depression with escitalopram in patients undergoing treatment for head and neck cancer: randomized, double-blind, placebo-controlled clinical trial. JAMA Otolaryngol Head Neck Surg 2013; 139:678.
  10. Li M, Kennedy EB, Byrne N, et al. Systematic review and meta-analysis of collaborative care interventions for depression in patients with cancer. Psychooncology 2016.
  11. Marmelstein H, Lesko L, Holland JC. Depression in the cancer patient. J Psychooncology 1992; 1:199.
  12. Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer 2006; 94:372.
  13. Ostuzzi G, Matcham F, Dauchy S, et al. Antidepressants for the treatment of depression in people with cancer. Cochrane Database Syst Rev 2015; :CD011006.
  14. Stoudemire, A, Fogel, BS, Gulley, LR. Psychopharmacology in the medically ill, In: Medical psychiatric practice, Stoudemire, A, Fogel, BS (Eds), American Psychiatric Press, Washington, DC, 1991. p.31.
  15. Massie MJ, Gagnon P, Holland JC. Depression and suicide in patients with cancer. J Pain Symptom Manage 1994; 9:325.
  16. Preskorn SH, Jerkovich GS. Central nervous system toxicity of tricyclic antidepressants: phenomenology, course, risk factors, and role of therapeutic drug monitoring. J Clin Psychopharmacol 1990; 10:88.
  17. Roose, S, Glassman, A. Cardiovascular effects of tricyclic antidepressants in depressed patients. J Clin Psychiatry Monograph Series 7, 1989.
  18. Holland JC, Romano SJ, Heiligenstein JH, et al. A controlled trial of fluoxetine and desipramine in depressed women with advanced cancer. Psychooncology 1998; 7:291.
  19. Fisch MJ, Loehrer PJ, Kristeller J, et al. Fluoxetine versus placebo in advanced cancer outpatients: a double-blinded trial of the Hoosier Oncology Group. J Clin Oncol 2003; 21:1937.
  20. Alper K, Schwartz KA, Kolts RL, Khan A. Seizure incidence in psychopharmacological clinical trials: an analysis of Food and Drug Administration (FDA) summary basis of approval reports. Biol Psychiatry 2007; 62:345.
  21. Theobald DE, Kirsh KL, Holtsclaw E, et al. An open-label, crossover trial of mirtazapine (15 and 30 mg) in cancer patients with pain and other distressing symptoms. J Pain Symptom Manage 2002; 23:442.
  22. Kaufmann MW, Murray GB, Cassem NH. Use of psychostimulants in medically ill depressed patients. Psychosomatics 1982; 23:817.
  23. Fernandez F, Adams F, Holmes VF, et al. Methylphenidate for depressive disorders in cancer patients. An alternative to standard antidepressants. Psychosomatics 1987; 28:455.
  24. Fernandez F, Adams F, Levy JK, et al. Cognitive impairment due to AIDS-related complex and its response to psychostimulants. Psychosomatics 1988; 29:38.
  25. Bruera E, Chadwick S, Brenneis C, et al. Methylphenidate associated with narcotics for the treatment of cancer pain. Cancer Treat Rep 1987; 71:67.
  26. Akechi T, Okuyama T, Onishi J, et al. Psychotherapy for depression among incurable cancer patients. Cochrane Database Syst Rev 2008; :CD005537.
  27. Parad, HJ, Parad, LG. Crisis Intervention: An introductory overview. In: Crisis Intervention: The practitioner's sourcebook for brief therapy, Parad, HJ, Parad, LG (Eds), Family Service America, Wisconsin 1990. p.3.
  28. Fawzy FI, Cousins N, Fawzy NW, et al. A structured psychiatric intervention for cancer patients. I. Changes over time in methods of coping and affective disturbance. Arch Gen Psychiatry 1990; 47:720.
  29. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989; 2:888.
  30. Stagl JM, Bouchard LC, Lechner SC, et al. Long-term psychological benefits of cognitive-behavioral stress management for women with breast cancer: 11-year follow-up of a randomized controlled trial. Cancer 2015; 121:1873.
  31. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med 2013; 173:960.
  32. Holland JC. Anxiety and cancer: the patient and the family. J Clin Psychiatry 1989; 50 Suppl:20.
  33. Massie, MJ. Anxiety, panic and phobias. In: Handbook of Psychooncology: Psychological care of the patient with cancer, Holland, JC, Rowland, J (Eds), Oxford University Press, New York 1989. p.300.
  34. Traeger L, Greer JA, Fernandez-Robles C, et al. Evidence-based treatment of anxiety in patients with cancer. J Clin Oncol 2012; 30:1197.
  35. Hollister LE. Pharmacotherapeutic considerations in anxiety disorders. J Clin Psychiatry 1986; 47 Suppl:33.
  36. Chouinard G, Young SN, Annable L. Antimanic effect of clonazepam. Biol Psychiatry 1983; 18:451.
  37. Walsh, TD. Adjuvant analgesic therapy in cancer pain. In: Advances in Pain Research and Therapy, vol. 16, Second International Congress on Cancer Pain, Foley, KM, Bonica, JJ, Ventafridda, V (Eds), Raven Press, New York 1990. p.155.
  38. Beaver WT, Wallenstein SL, Houde RW, Rogers A. A comparison of the analgesic effects of methotrimeprazine and morphine in patients with cancer. Clin Pharmacol Ther 1966; 7:436.
  39. Oliver DJ. The use of methotrimeprazine in terminal care. Br J Clin Pract 1985; 39:339.
  40. Beaver, WT, Feise, G. Comparison of the analgesic effects of morphine, hydroxyzine and their combination in patients with post-operative pain. In: Advances in Pain Research and Therapy, Bonica, JJ, Albe-Fessard (Eds), Raven Press, New York 1976. p.553.
  41. Passik SD, Dugan W, McDonald MV, et al. Oncologists' recognition of depression in their patients with cancer. J Clin Oncol 1998; 16:1594.
  42. Passik SD, Cooper M. Complicated delirium in a cancer patient successfully treated with olanzapine. J Pain Symptom Manage 1999; 17:219.
  43. Liebowitz MR. Imipramine in the treatment of panic disorder and its complications. Psychiatr Clin North Am 1985; 8:37.
  44. Popkin MK, Callies AL, Mackenzie TB. The outcome of antidepressant use in the medically ill. Arch Gen Psychiatry 1985; 42:1160.
  45. Robinson D, Napoliello MJ, Schenk J. The safety and usefulness of buspirone as an anxiolytic drug in elderly versus young patients. Clin Ther 1988; 10:740.
  46. Ross S, Bossis A, Guss J, et al. Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. J Psychopharmacol 2016; 30:1165.
  47. Massie MJ, Holland JC, Straker N. Psychotherapeutic interventions. In: Handbook of Psychooncology: Psychological Care of the Patient with Cancer, Holland JC, Rowland JH (Eds), Oxford University Press, New York 1989. p.455.
  48. Breitbart W. Psychiatric management of cancer pain. Cancer 1989; 63:2336.
  49. Holland JC, Morrow GR, Schmale A, et al. A randomized clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms. J Clin Oncol 1991; 9:1004.
  50. Jacobsen PB, Meade CD, Stein KD, et al. Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol 2002; 20:2851.
  51. Krischer MM, Xu P, Meade CD, Jacobsen PB. Self-administered stress management training in patients undergoing radiotherapy. J Clin Oncol 2007; 25:4657.
  52. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med 2013.
  53. Johnson JA, Rash JA, Campbell TS, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev 2016; 27:20.
  54. Lipowski ZJ. Delirium (acute confusional states). JAMA 1987; 258:1789.
  55. Murray, GB. Confusion, delirium, and dementia. In: Massachusetts General Hospital Handbook of General Hospital Psychiatry, 2nd ed, Hackett, T, Cassem, NH (Eds), PSG Publishing Company, Littleton, MA 1987. p.84.
  56. Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996; 153:231.
  57. Massie MJ, Holland J, Glass E. Delirium in terminally ill cancer patients. Am J Psychiatry 1983; 140:1048.
  58. Boettger S, Jenewein J, Breitbart W. Haloperidol, risperidone, olanzapine and aripiprazole in the management of delirium: A comparison of efficacy, safety, and side effects. Palliat Support Care 2015; 13:1079.
  59. Fann JR, Alfano CM, Roth-Roemer S, et al. Impact of delirium on cognition, distress, and health-related quality of life after hematopoietic stem-cell transplantation. J Clin Oncol 2007; 25:1223.
  60. Caraceni A, Nanni O, Maltoni M, et al. Impact of delirium on the short term prognosis of advanced cancer patients. Italian Multicenter Study Group on Palliative Care. Cancer 2000; 89:1145.
  61. Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 2000; 160:786.
  62. Boettger S, Jenewein J, Breitbart W. Delirium and severe illness: Etiologies, severity of delirium and phenomenological differences. Palliat Support Care 2015; 13:1087.