Nurses Can Help Patients With Cancer Manage the Complexity of Comorbid Psychiatric Disorders

Many factors contribute to mental health disorders, such as genetics, fetal exposure, toxins, exogenous factors, and trauma. Furthermore, brain disfunction can be induced by the malignancy in the central nervous system, medications, sleep deprivation, and malnutrition. Murphy-Ende said that patients with cancer have a higher incidence of mental health disorders than the general population and the disorders may be undiagnosed or not known to oncology staff.

Patients with mental health disorders may experience significant disturbances in cognition, emotion regulation, or behavior, Murphy-Ende said. She emphasized that nurses must remember the rule of “first do no harm” by being observant for signs of mental health distress that warrant intervention.

Oncology nurses should obtain patients’ mental health histories and medication lists and watch for altered cognitive function and behavior. When prolonged distress interferes with functioning or patients express thoughts of suicide or the desire to hasten death, referral to a psychologist, psychiatrist or psychiatric-mental health nurse practitioner is critical.

“In crisis, ultimately, it’s about control, identity, relationships, and meaning—meaning of the diagnosis, meaning of life, meaning of suffering, and meaning of death,” Murphy-Ende said.

The biologic changes associated with cancer physiology may have implications for the development or manifestation of anxiety disorders. Anxiety is the behavioral outcome of the brain responding to its environment, including genes, cells, and systems, Murphy-Ende explained, and it’s a normal part of the body’s natural defense. However, anxiety becomes a disorder when it has a significant impact on a patient’s ability to function.

Patients who have underlying generalized anxiety disorder (GAD) or panic disorder are more likely to have symptoms relapse or worsen after a cancer diagnosis. Among patients with GAD, 50%–90% have a comorbid mental disorder, Murphy-Ende said. Treatments can include medication, psychotherapy, meditation, and relaxation training.

Management of bipolar I and II disorder must continue during cancer treatment, and any prescribed medications cannot be suddenly stopped. Nurses should have patients provide full drug lists and ask why they are taking each medication, because some may be used off-label. Additionally, Murphy-Ende cautioned that some medication lists may be incomplete or outdated, so nurses must ask patients what they are taking and what medications they have stopped taking at every visit.

Bipolar II, characterized by episodes of hypomania (which may be subtle) interspersed with major depression, is mistakenly considered a minor form of bipolar I, Murphy-Ende said. Patients with bipolar II experience the same risk for substance use disorder and suicide as those with bipolar I and, therefore, require the same level of vigilance.

Patients may have a history of post-traumatic stress disorder (PTSD) or develop PTSD after a cancer diagnosis. Characterized by ongoing intrusive thoughts, reexperiencing trauma, emotional numbness, avoidance of reminders of the trauma, hypervigilance, and physiologic arousal, PTSD is believed to affect 8% of people in the general population but up to 35% of patients with cancer, Murphy-Ende said.

When patients experience traumatic events, a defense mechanism is to block memories. Sometimes avoiding the memories can prevent emotional processing, resulting in intrusive thoughts and re-experiencing the traumatic emotions.

Murphy-End explained that intensive and immediate psychological support from a trained therapist provides an opportunity for the patient to give a narrative of their traumatic experience, which helps prevent disorganization of trauma memories that interfere with information processing. Medications, cognitive behavioral and exposure therapy, desensitization, stress reduction (e.g., guided imagery, progressive muscle relaxation), and supportive, expressive group therapy are helpful.

Vigilant nursing support results in the best outcomes for patients with psychiatric disorders. “Nurses are the most likely members of the healthcare team to pay attention to mental health disorders in their patients and therefore keep stable and safe,” Murphy-Ende concluded.