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Keywords:

  • cancer;
  • consultation-liaison psychiatry;
  • informed consent;
  • notice;
  • schizophrenia

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENT
  8. REFERENCES

Abstract  Patients with schizophrenia who develop cancer often have a variety of complicated medical and psychiatric problems. Problems associated with receiving a diagnosis of cancer and with understanding or cooperating with medical treatment may develop. Research in managing and treating schizophrenia patients with cancer is scarce. Presented herein is the experience of the authors’ consultation–liaison psychiatry service in treating patients with schizophrenia who have cancer, and discussion of the medical management of such cases. Fourteen patients were treated between April 1999 and March 2003 and included patients receiving consultation psychiatric services at Shimane University Hospital as well as patients referred from other psychiatric hospitals. These patients were divided into two groups based on whether they were amenable to cancer treatment or not. The treated group consisted of patients who accepted cancer treatment, and the untreated group consisted of patients who refused or interrupted the cancer treatment. The clinical course, clinical psychiatric symptoms, problems in understanding cancer, cancer treatment course and convalescence were retrospectively assessed. Psychiatric symptoms and state were measured using the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS). The mean of the duration of schizophrenia in these two groups was not significantly different. The mean scores on measures of psychiatric symptoms in each group (treated and untreated) were as follows: BPRS, 45.3 ± 15.4 and 64.9 ± 9.2 (P < 0.05); positive symptoms scores on PANSS, 14.4 ± 8.8 and 20.6 ± 6.0 (NS); negative symptoms scores on PANSS, 20.6 ± 4.7 and 33.6 ± 4.4 (P < 0.01); and total scores on PANSS, 31.7 ± 7.0 and 48.6 ± 7.4 (P < 0.01). Patients with severe negative symptoms had greater difficulty understanding and cooperating with the cancer treatment. Regarding cancer stage, when cancer was discovered, the disease had already advanced and was no longer amenable to first-line treatment. Regarding notification of the diagnosis, it was rarely possible to give sufficiently early notice to patients in the untreated group. The important role of consultation–liaison psychiatrist in treating cancer patients is suggested. Some steps are proposed for managing schizophrenia patients with cancer who are not able to give informed consent.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENT
  8. REFERENCES

Schizophrenia patients, caregivers, and physicians frequently may be unaware of symptoms from physical diseases, and diseases remain undiagnosed and untreated for a long time. Consequently, their physical diseases are identified only when they appear in acute potentially lethal forms that lead to admission.1,2 Schizophrenia patients may receive less than adequate health care. In particular, patients with schizophrenia who have cancer often have a variety of complicated medical and psychiatric problems. Such patients experience difficulties coping with the diagnosis and treatment of cancer and may ignore warning signs and symptoms. Undiagnosed and untreated medical illness can result in significant morbidity for schizophrenia patients.3 Psychoses and cognitive impairment play a major role in delay and non-compliance with diagnosis and cancer treatment.1,4 Often these patients can neither understand the diagnosis of cancer nor cooperate with treatment because of severe psychiatric symptoms or cognitive impairment. Even when patients accept the diagnosis and undergo cancer treatment and/or long-term palliative treatment, they need assistance in achieving psychiatric stability and in understanding their disease.5

There are few reports describing the problems of schizophrenia patients with cancer. We present our experience treating schizophrenia patients with cancer receiving consultation–liaison services, and discuss the medical management of such cases.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENT
  8. REFERENCES

Fourteen patients with various types of cancer who also met DSM-IV criteria for schizophrenia were selected from the records of the psychiatry unit of Shimane University Hospital. All patients were treated between April 1999 and March 2003 and they included patients receiving consultation psychiatric services at Shimane University Hospital as well as patients referred from other psychiatric hospitals. We retrospectively assessed the clinical course, clinical symptoms, problems in understanding cancer, the treatment course and convalescence. Psychiatric symptoms and state were measured using the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS) at the initial interview. We divided the patients into two groups. The treated group consisted of patients who accepted cancer treatment, and the untreated group consisted of patients who refused or interrupted the cancer treatment.

Analysis was conducted using unpaired t-tests.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENT
  8. REFERENCES

Patient profiles are summarized in Table 1. The treated group consisted of seven subjects (one male and six female; mean age: 52 ± 10.8 years), four were outpatients and three were psychiatric inpatients. The untreated group consisted of seven subjects (two male and five female; mean age: 60.7 ± 13.9 years), two were outpatients and five were psychiatric inpatients. The mean of the duration of schizophrenia in these two groups was 23.2 ± 11.2 years and 27.1 ± 15.2 years, respectively. There was no significant difference in duration. The mean scores on measures of psychiatric symptoms in each group (treated and untreated) were as follows: BPRS, 45.3 ± 15.4 and 64.9 ± 9.2 (P < 0.05); positive symptoms scores on PANSS, 14.4 ± 8.8 and 20.6 ± 6.0 (NS); negative symptoms scores on PANSS, 20.6 ± 4.7 and 33.6 ± 4.4 (P < 0.01); and total scores on PANSS, 31.7 ± 7.0 and 48.6 ± 7.4 (P < 0.01). The sites of cancer were as follows: five in the digestive system, three in the mammary glands, three in blood, two in the uterus and one in the skin. According to the tumor, node, metastasis staging system (TNM) classification, all subjects in the treated group ranged from grade 0 to III, while four subjects in the untreated group were in grade IV, indicating advanced disease (Table 1).

Table 1.  Schizophrenia subjects
CaseSexAge (years)CancerDuration of cancerCancer stage (TNM)Informed of cancer diagnosisUnderstood cancer diagnosis and treatmentWard of admission
  1. ○, good understanding; ▵, moderate understanding; ×, little or no understanding.

Treated group
 1F49Uterus1 monthIIbGynecology
 2F43Skin?II–IIIDermatology
 3F52Uterus3 months0Gynecology
 4M36Leukemia1 month/Internal medicine
 5F54Esophagus2 years 2 months?×Surgery
 6F67Breast3 monthsIISurgery
 7F63Stomach?I×Psychiatry
Untreated group
 8F61Colon1 monthIV×Surgery[RIGHTWARDS ARROW]Psychiatry
 9F59Breast1 monthIV××Psychiatry
 10F60Breast4 years 2 monthsIV×Surgery
 11F33Leukemia14 years/×Psychiatry
 12M63Colon1 monthIV××Psychiatry
 13M75Mal. lymphoma6 months/××Internal Medicine[RIGHTWARDS ARROW] Psychiatry
 14F74Colon??××Psychiatry

In the treated group, notification of cancer diagnosis was fully obtained from five patients; understanding of the diagnosis and treatment was completed in four subjects, but not in three. Four patients (2,3,4,6) understood the diagnosis and cooperated with the cancer treatment. Three patients (1,5,7) had an imperfect understanding of cancer diagnosis and treatment. Patient 5 received an explanation of ‘esophageal ulcer’ and patient 7 received an explanation of ‘stomach polyps’. They, however, were able to complete the cancer treatment.

In the untreated group, notification were obtained from two patients; understanding of the diagnosis and treatment was completed for only two patients (10,11) and not completed for five patients (8,9,12,13,14). None of these patients could understand their condition or the diagnosis. Insight and judgment were also poor. They did not consent to cancer treatment. Patient 8 understood the cancer as a ‘gastric ulcer’, patient 9 understood the diagnosis as ‘something bad’ and patient 11 complained that ‘medical treatment was not needed’. There was no aggravation of the psychiatric symptoms after notification except in patient 1.

As a result, five patients in the treated group (2,3,4,5,6) were hospitalized and treated in the internal medicine or surgery ward, not in the psychiatric ward from the first day of admission, because they did not present with severe psychiatric symptoms. Three subjects were discharged to their home, four subjects were transferred to the psychiatric hospital. In the untreated group, four subjects presented with severe psychiatric symptoms so they were hospitalized and received psychiatric treatment in the psychiatric ward from the first. Although cancer treatment was attempted, treatment was interrupted by the patient. Although two subjects (patients 8,13) were initially hospitalized in the surgery ward, they were transferred to the psychiatric ward because of worsening psychiatric symptoms. Therefore, it became impossible to continue the cancer treatment. Five patients (9,10,12,13,14) returned to the original psychiatric hospital and two patients (8,11) were discharged to their home. Results of reality-testing and/or judgment deteriorated in the patients of the untreated group. These patients had difficulty in medical decision-making and they demonstrated vague denial of cancer.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENT
  8. REFERENCES

Patients with schizophrenia may not volunteer medical complaints or may have difficulty communicating their problem and medical history to the physicians.6 When schizophrenia patients with severe psychiatric symptoms develop somatic diseases, it is often difficult for them to be admitted to a general hospital because such patients are difficult to treat and manage in this setting. In such cases, patients with somatic complications often need treatment in a psychiatric ward in the general hospital.7 In other cases, when psychiatric symptoms are mild, attending psychiatrists may treat schizophrenia patients in the general ward using the consultation–liaison service.5 In particular, patients with schizophrenia who have cancer often have a variety of complicated medical and psychiatric problems. Problems such as notification of the diagnosis, understanding of the critical nature of the disease and compliance with cancer treatment become important. These psychosocial factors influence medical decision-making and cause delays in obtaining cancer treatment.1,4,7

Medical comorbidity including cancer in schizophrenia has been studied to a much smaller extent.1,6 There currently are few proposed guidelines for management and treatment of such cases. Jeste et al. suggested the need for systematic assessment of physical illness in patients with schizophrenia.1 Further research is required in managing and treating schizophrenia patients with cancer.

In the present report, 14 patients received medical treatment at Shimane University Hospital between 1999 and 2003. The treated group consisted of seven subjects and the untreated group consisted of seven subjects. Although the duration of schizophrenia did not differ significantly between the two groups, there were more outpatients in the treated group. Patients must be diagnosed and effectively treated, but the patient’s psychiatric symptoms and deteriorated cognitive function may interfere with effective management.3 Jeste et al. demonstrated that the more severe schizophrenia positive symptoms that a patient has, the more likely it is that both the patient and the health-care staff may underestimate or ignore co-occurring medical illness using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G8).1 In the present study, there was difference in BPRS scores, and higher scores for both negative symptoms and total symptoms on PANSS suggested that patients with severe negative symptoms have greater difficulty in understanding and cooperating with cancer treatment.

Regarding cancer stage, there were many subjects in stage IV (four patients) among inpatients from psychiatric hospitals. Therefore, when cancer was discovered, the disease had already advanced.

Regarding notification of the diagnosis, we were able to give full notification to five of seven patients in the treated group, but to only two of seven patients in the untreated group. We rarely succeeded in informing patients of their diagnosis in the untreated group. Although it was possible for patients in the treated group to understand that their disease was cancer, there were no patients in the untreated group who could understand and make important medical treatment decisions. Although patients in the treated group could be managed in the general ward, almost all of those in the untreated group had to be treated in the psychiatric ward. It was difficult to manage and treat them in a general ward for somatic disease.

Informed consent consists of sufficient explanation and information offered by the physician combined with the patient’s ability to understand and make rational decisions based on free will. The purpose of informed consent is to give the patient an understanding of the illness and their physical condition and to facilitate their active participation in medical treatment. Regarding informed consent, patients have the right to make their own determinations regarding treatment, whether this involves the acceptance or refusal of a suggested course.9 However, in schizophrenia patients, there are problems in the patient’s ability to understand their condition as well as problems in their ability to provide consent.4,7 Moreover, there is also a concern about aggravating schizophrenia symptoms when informing such patients of their diagnosis.

In Japan, physicians do not always inform cancer patients of their diagnosis. When a physician cannot obtain consent for medical treatment from a patient, the physician generally obtains consent from his/her family. Therefore, schizophrenia patients may be late for cancer treatment.

In the present series, there were many patients who could not give consent or cooperate despite the necessity for cancer treatment. Furthermore, when we could not gain consent from the patient’s family, we could not treat the patient. We regretted that we could not provide compulsory cancer treatment to these schizophrenia patients. However, there was one patient (subject 1) who became able to receive cancer treatment after a psychiatrist treated and controlled her psychiatric symptoms. Thus, consultation–liaison psychiatrists play an important role in treating cancer patients. As for patient 5, although he was not notified of the cancer, and was not able to understand the disease, cancer treatment was performed after the family consented.

In cases where consent and cooperation for treatment cannot be obtained, we are required to try the following steps.

(1) First, we attempt to provide psychiatric treatment.

(2) We repeatedly attempt to persuade the patient to receive cancer treatment.

(3) If we cannot obtain their consent, we try to obtain consent from the family. If a patient is found to be mentally incompetent to make a treatment decision, proxy or family consent usually is obtained from a person responsible for the patient’s care and closely associated with that patient.9

(4) When these patients receive cancer treatment, we psychiatrists must make efforts to stabilize the patient’s psychiatric symptoms.

Despite these efforts, there may still be some untreatable cases.

Psychiatrists must make efforts to promote a better understanding of schizophrenia among physicians. Medical physicians may contribute to delay and interruption of treatment. Such delays and interruptions may result from having only a superficial and prejudiced understanding of schizophrenia patients. Physicians sometimes easily present plausible but minimizing explanations for the patient’s psychiatric signs and symptoms.7 The ability to successfully diagnose and treat concurrent medical illness in the schizophrenia patients will depend on the physician’s ability to be flexible and to understand the patient’s underlying disorder.3 Physicians have an obligation to be alert for signs and symptoms of physical disease.6

Guidelines for cancer treatment in patients with schizophrenia for physicians and psychiatrists are desired. Such guidelines could contribute to appropriately notifying patients of their diagnosis and obtaining consent to medically treat their cancer.

ACKNOWLEDGMENT

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENT
  8. REFERENCES

The present study was supported in part by a Grant-in-Aid of the Japanese Ministry of Health, Labor and Welfare.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENT
  8. REFERENCES
  • 1
    Jeste DV, Gladsjo JA, Lindamer LA et al. Medical comorbidity in schizophrenia. Schizophr. Bull. 1996; 22: 413430.
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    Munk-Jorgensen P, Mors O, Mortensen PB et al. The schizophrenic patient in the somatic hospital. Acta Psychiatr. Scand. 2000; 102: 9699.
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    Adler LE, Griffith JM. Concurrent medical illness in the schizophrenic patient. Epidemiology, diagnosis, and management. Schizophr. Res. 1991; 4: 91107.
  • 4
    Kunkel EJ, Woods CM, Rodgers C et al. Consultations for maladaptive denial of illness in patients with cancer: psychiatric disorders that result in noncompliance. Psychooncology 1997; 6: 139149.
  • 5
    Kelly BD, Shanley D. Terminal illness and schizophrenia. J. Palliat. Care 2000; 16: 5557.
  • 6
    Goldman LS. Medical illness in patients with schizophrenia. J. Clin. Psychiatry 1999; 60: 1015.
  • 7
    Schwarts CE, Steinmuller RI, Dubler N. The medical psychiatrist as physician for the chronically mentally ill. Gen. Hosp. Psychiatry 1998; 20: 5261.
  • 8
    Miller MD, Paradis CF, Houck PR et al. Rating chronic medical illness burden in geropsychiatric practice and research: application of the cumulative illness rating scale (CIRS). Psychiatry Res. 1992; 41: 237248.
  • 9
    Hartman TS, Weitzner MA, Santana C et al. Cancer and folie a deux. Cancer Pract. 2001; 9: 290294.