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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 40  |  Issue : 2  |  Page : 123-126

Pattern of referral to a consultation-liaison psychiatry service in an Egyptian cancer center


1 Psychiatry Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
2 Clinical Oncology Department, Cairo University, Cairo, Egypt
3 Department of Public Health, Theodor Bilharz Institute, Giza, Egypt
4 Palliative Medicine Unit, Kasr Al-Ainy Center of Clinical Oncology and Nuclear Medicine, Cairo University, Cairo, Egypt

Date of Submission30-Apr-2019
Date of Acceptance02-Jun-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Mahmoud A El Batrawi
Psychiatry Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejpsy.ejpsy_19_19

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  Abstract 


Aim/Objective/Background Integration of consultation-liaison(C-L) psychiatry services in palliative care units in oncology departments is very limited in Egypt. A new dedicated C-L psychiatry service was recently established within the premises of the palliative care clinic in Kasr al Ainy Center for Clinical Oncology and Nuclear Medicine (NEMROCK), Cairo, Egypt. The aim of this study was to examine the characteristics, diagnoses and follow up of patients referred to this new service in a year period.
Methods The clinical and psychiatric characteristics of all consecutive oncology patients (n=44) referred to this new C-L psychiatric service in a year period were examined. Psychiatric diagnosis was made according to the Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edition (DSM 5).
Results A total number of 44 patients (12 males and 32 females) were referred to the C-L clinic during the study period. Half of the patients had breast cancer.The other half was a diverse group involving different sites. In the advanced stage of cancer, males were significantly more represented than the females. As regards psychiatric diagnosis, the most common category was adjustment disorder (22 patients) followed by major depression (11 patients). Six of the patients had non-psychiatric distress, two had a primary psychotic disorder, two had substance related disorder and one had a major cognitive disorder. Causes of suffering in the non-psychiatric distressed group included lack of adequate medical information, physical concerns, existential concerns and family concerns. Most patients received psychotropic medication.
Conclusions The scope and severity of psychiatric morbidity and distress detected in the referred oncology patients reflects the need to integrate C-L psychiatric services within psycho-oncological and palliative care clinics.

Keywords: consultation-liaison psychiatry, Egypt, oncology


How to cite this article:
El Batrawi MA, Gaber M, Mekheimar SI, Alsirafy SA. Pattern of referral to a consultation-liaison psychiatry service in an Egyptian cancer center. Egypt J Psychiatr 2019;40:123-6

How to cite this URL:
El Batrawi MA, Gaber M, Mekheimar SI, Alsirafy SA. Pattern of referral to a consultation-liaison psychiatry service in an Egyptian cancer center. Egypt J Psychiatr [serial online] 2019 [cited 2019 Nov 19];40:123-6. Available from: http://new.ejpsy.eg.net/text.asp?2019/40/2/123/262552




  Introduction Top


Although research in psycho-oncology started in Egypt relatively early (El Batrawi, 1990), integration of consultation-liaison psychiatry (CLP) services in oncology departments has not taken place. Reported barriers to collaboration between psychiatry and oncology include the misinterpretation that psychiatry is excessively medicalized, that psychiatric treatment is too difficult to practice in daily oncological settings, and that patients refuse referral for psychiatric treatment (Ogawa et al., 2012).

In 2015, a CLP service was started at the Clinical Oncology Department at Kasr Al-Ainy School of Medicine, Cairo University. The CLP service is a once weekly consultation-liaison clinic for patients with cancer referred from the oncology service for psychiatric evaluation. The clinic is conducted by a CLP Consultant with experience in psycho-oncology and existential psychotherapy together with an oncology resident for the dual purpose of assistance and exposure to psycho-oncological cases. All patients referred to the CLP clinic receive psychological support which is predominantly informed by existential and psychodynamic life narrative principles.

The aim of this study is to report the pattern of referral to the first oncology center-based CLP service in Egypt.


  Patients and methods Top


This is a descriptive study of all consecutive cases referred from the oncology service to the new CLP clinic in a 1-year period from October 2015 to October 2016. The demographic data, presenting complaints, stage of cancer, past history of psychiatric illness, cancer treatment status, psychiatric diagnosis, and a psychiatric formulation of the case were recorded in a performa developed by the authors. Psychiatric diagnosis was made according to Diagnostic and Statistical Manual of Psychiatric Disorders, 5th ed.

Descriptive statistical analysis and χ2-test for categorical variables were used when indicated.


  Results Top


The study included 44 patients, of whom 32 (72.7%) were females. The mean age of patients was 46.3 years (range: 10–79). The characteristics of the patients are shown in [Table 1].
Table 1 Summary characteristics of the sample (N=44)

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Males were more likely to have an advanced stage (P<0.001). Two (4.54%) female patients with breast cancer diagnosed with adjustment disorder with depressed mood reported to have taken psychotropic medication before for treatment of depression.

[Table 2] shows the classification of patients according to psychiatric diagnosis. The most common diagnosis was adjustment disorder and the least was distributed equally between psychotic and substance-related disorders.
Table 2 Patients classified according to psychiatric diagnosis

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As seen from [Table 2], causes of suffering in patients with nonpsychiatric distress included lack of adequate medical information, physical concerns such as shortness of breath, existential concerns such as feelings of being in a maze, and family concerns. All patients with nonpsychiatric distress received psychological support.

Psychotropic medication were prescribed to all patients except the six patients with nonpsychiatric distress, two female patients with adjustment disorder, and one male patient with substance-related disorder. Most commonly prescribed psychotropic drugs in order of frequency were antidepressants (72.64%) followed by major tranquilizers (27.24%), mood stabilizers (6.81%), benztropine (6.81%), and lastly atomoxetine and diazepam (2.27% each).


  Discussion Top


In this study, we described the activity of a newly established CLP clinic service in a palliative care oncology setting. The number of referred patients presenting for psychiatric evaluation during the study period (n=44) was probably an underestimate given the fact that most patients with cancer do not adhere to referral to the psychiatric facilities for different reasons (Shimizu et al., 2009).

Regarding the prevalence of diagnosable psychiatric disorders, adjustment disorders were the most common (49.9%) followed by major depression (25%). An earlier Egyptian study that assessed depression in patients with cancer using the Zung self-rating scale for depression and the Schedules for Clinical Assessment in Neuropsychiatry found a prevalence rate of 6.6 and 46.7% of major depression and adjustment disorder, respectively (El Batrawi et al., 2000). Moreover, Miovic and Block (2007) reported prevalence rates of major depression in the range from 5 to 26% and rates of 11–35% for adjustment disorder. However, given the fact that in the former studies detection of psychiatric morbidity was essentially made directly in the oncology pool whereas in the present study it was made on a sample of oncology patients referred to the CLP clinic on the basis of suspected psychiatric morbidity, a direct comparison of the results will be misleading. However, given the reported logistic stressors confronting patients with cancer in Egypt, for example, in the means of transportation, it is expected that in lower-income countries such as Egypt, patients with cancer suffer considerably to reach their medical destination, a factor which is suggested to increase their suffering and distress.

Anxiety was found among our patients in the context of adjustment disorder with mixed anxiety depression with a prevalence rate of 15.9%. Moreover, given the fact that the patients were referred during treatment after the initial shock of diagnosis has subsided as well as the suggested role religion plays in helping patients with cancer in Egypt to accept their predicament (El Batrawi,1990; Elsheshtawy et al., 2014), it is conceivable that these factors contributed to the absence of pure anxiety disorders.

Nonpsychiatric distress was found in 13.6% of the referred patients. A variety of existential, physical, familial, and medical service-related concerns appear to have played a role in its occurrence. Although patients in this group who suffered from existential concerns were not in our opinion pathologically demoralized yet differential diagnosis with demoralization syndrome was not straightforward. All of the patients in this group were managed by psychological support only. The referral of these patients to the CLP service may point to that type of distress in oncological patients which often passes unnoticed and is often considered as an ‘unmet need’ (Carlson et al., 2012). This point reflects the clinical acumen and efforts oncologists do to understand their patients not only as harbingers of disease but also as human beings confronting ‘the most fundamental questions related to the human condition: the meaning of life, the fear of suffering and the problem of living in the present while facing the certainty of death’ (Rodin, 2009). Moreover, the 13.6% prevalence rate of referred patients with nonpsychiatric distress is comparable with prevalence reported by others (Kissane and Smith 1996), a finding that supports the reported significance of identifying unmet needs by efficient screening tools (Carlson et al., 2012). Regarding sex differences, male patients in the advanced stage of cancer were significantly more represented than the females. This is probably to the fact that no male patients were to be found in the ‘nonpsychiatric distress’ group. In this regard, it is possible that being the bread winners for their families, the male patients were more at risk to be stigmatized by the functional limitations of their illness, a condition which made them hide their distress as long as they were able to work.

The two patients who had psychotic disorders (one with schizoaffective disorder bipolar type and the other with delusional disorder) managed their breast cancer experience courageously without apparent exacerbation of their psychosis. Several reports have advocated the use of narrative rather than scientific discourse to understand the complexity of the traumatic experience of having cancer breast (Manderson and Stirling, 2007).

The majority (79.5%) of the sample received psychotropic medication. This prevalence is higher than that reported by others (Kissane and Smith, 1996). However, these figures point to the pivotal role psychotropic medication play in addressing the distress of patients with cancer especially in a CLP service like the present one which adopts mainly a single consultant approach model. Therefore, measures to adopt a more multidisciplinary CLP approach with recruitment of motivated personnel with different experiences in offering compassionate care and communication for patients with cancer is strongly recommended.

Regarding follow-up, a big proportion of the patients with adjustment disorder and major depression did not come for follow-up. Communicating with the latter group in oncology clinics or through telephone in their homes is recommended to convey a message of authentic interest in their distress and to have feedback of their initial visit in the CLP clinic.

The main limitation in our study is lack of standardized rating scales and structured interviews. This prevents direct comparison of the results with those from other studies using validated research tools. However, the observations and data yielded in this study are felt to be useful as a building block for further implementation of evidence-based research in CLP services in oncology in Egypt.[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carlson L, Waller A, Mitchell A (2012). Screening for distress and unmet needs in patients with cancer: review and recommendations. J Clin Oncol 30:1160–1177.  Back to cited text no. 1
    
2.
El Batrawi M (1990). Psychosocial variables and personality characteristics in cancer patients. Cairo, Egypt: Doctorate Thesis (Unpublished). Cairo, Cairo University.  Back to cited text no. 2
    
3.
El Batrawi M, Moussa M, Abd Al Aal H (2000). Screening for depression in cancer using the Zung self rating scale. Egypt J Psychiatr 23:37–45.  Back to cited text no. 3
    
4.
Elsheshtawy EA, Abo-Elez WF, Ashour HS et al. (2014). Coping strategies in Egyptian ladies with breast cancer. Breast Cancer (Auckl) 8:97–102.  Back to cited text no. 4
    
5.
Kissane DW, Smith G (1996). Consultation-liaison psychiatry in an Australian oncology unit. Aust N Z J Psychiatry 30:397–404.  Back to cited text no. 5
    
6.
Manderson L, Stirling L (2007). The absent breast: speaking of the mastectomized body. Feminism Psychol 17:75–92.  Back to cited text no. 6
    
7.
Miovic M, Block S (2007). Psychiatric disorders in advanced cancer. Cancer 110:1665–1676.  Back to cited text no. 7
    
8.
Ogawa A, Nouno J, Shirai Y et al. (2012). Availability of psychiatric consultation-liaison services as an integral component of palliative care programs at japanese cancer hospitals. Jpn J Clin Oncol 42:42–45.  Back to cited text no. 8
    
9.
Rodin G (2009). Individual psychotherapy for the patient with advanced disease. In: Chochinov HM, Breitbart W, editors. Handbook of psychiatry in palliative medicine. New York, NY: Oxford University Press.  Back to cited text no. 9
    
10.
Shimizu K, Ishibashi Y, Umezawa S et al. (2009). Feasibility and usefulness of the ‘Distress Screening Program in Ambulatory Care’ in clinical oncology practice. Psychooncology 19:718–725.  Back to cited text no. 10
    



 
 
    Tables

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