A randomized clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms.

A randomized nonblinded study was performed in three cancer centers to test over a 10-day period the efficacy of (1) a triazolobenzodiazepine, alprazolam, 0.5 mg three times a day and (2) use of a behavioral technique in which patients were trained in progressive muscle relaxation at an initial session with a behavioral psychologist and then asked to listen at home to an audiotape of the session three times a day. Of 147 cancer patients who met entry levels of distress and completed the study, uncontrolled for site or disease stage, 70 were randomized to drug, 77 to relaxation. Four measures of anxiety and depression were used: Covi, Raskin, Affects Balance, and Symptoms Checklist-90 (SCL-90). Results showed that both treatment arms resulted in significant (P less than .001) decrease in observer and patient-reported anxious and depressed mood symptoms. Although both treatment arms were effective, patients receiving the drug showed a slightly more rapid decrease in anxiety and greater reduction of depressive symptoms. These findings confirm efficacy of both alprazolam and relaxation to reduce cancer-related anxiety and depression. As safe, inexpensive, and effective interventions, physicians should consider their use in cancer patients experiencing anxiety and depressive symptoms.

Informed consent for investigational chemotherapy: patients' and physicians' perceptions.

One hundred forty-four patients and 68 physicians at three cancer centers were studied for their perceptions of the consent procedure, in which they participated one to three weeks earlier, for chemotherapy by one of 65 investigational protocols. Patients recalled the procedure positively and relied heavily on physician's advice. They felt most physicians wanted them to accept; 29% felt their participation in the decision was not encouraged. Primary reasons for accepting were trust in the physician, belief the treatment would help, and fear the disease (viewed as highly serious) would get worse without it. Nearly a fourth did not recall the information given that treatment was investigational. The consent form played no role in decision-making for 69%. Physicians believed therapeutic benefits would exceed potential problems for most patients; they viewed 41% of the patients as less than eager for details of treatment, a third as avoiding the seriousness of the discussion, and a third as passive in decision-making. The perceptual set of both parties places inadvertent constraint on patients' autonomy in decision making.

Well-being of cancer survivors.

One hundred and four cancer survivors 3 years past their last cancer treatment reported a significantly lower sense of self-control and more general health worries than a matched sample of healthy controls. The two groups did not differ on variables of anxiety, depression, positive well being, and vitality or on two composite scores of mental and general well-being. The well-being scores of the survivors from three geographically distinct cancer centers revealed no significant differences among centers on the composite or any of the individual subscores. Sociodemographic and treatment variables revealed only marriage and no change in job were significantly related to the amount of general well-being experienced.

The prevalence of psychiatric disorders among cancer patients.

Two hundred fifteen randomly accessed cancer patients who were new admissions to three collaborating cancer centers were examined for the presence of formal psychiatric disorder. Each patient was assessed in a common protocol via a psychiatric interview and standardized psychological tests. The American Psychiatric Association's DSM-III diagnostic system was used in making the diagnoses. Results indicated that 47% of the patients received a DSM-III diagnosis, with 44% being diagnosed as manifesting a clinical syndrome and 3% with personality disorders. Approximately 68% of the psychiatric diagnoses consisted of adjustment disorders, with 13% representing major affective disorders (depression). The remaining diagnoses were split among organic mental disorders (8%), personality disorders (7%), and anxiety disorders (4%). Approximately 85% of those patients with a positive psychiatric condition were experiencing a disorder with depression or anxiety as the central symptom. The large majority of conditions were judged to represent highly treatable disorders.

Pretreatment behavioral profiles associated with subsequent psychosocial adjustment in radiation therapy patients: a prospective study.

A clinically derived system of judging cancer patients' engagement, reality testing and degree of arousal during a pretreatment consultation was found predictive of psychosocial problems or no problems reported by sixty cancer patients one month after starting radiation therapy. Independent ratings of psychosocial problems by the treating oncologists, nurses and radiation therapists three months after starting treatment were also found significantly associated with the pretreatment composite. Disease, treatment and demographic factors were not predictive of psychosocial problems and were not associated with the pretreatment clinical composite. Follow-up observations at six months and eighteen to twenty-four months of forty-four and twenty-four of the original patients available for study revealed there was no continuing association between their pretreatment clinical composites and psychosocial problem ratings.

Development of brief measures of psychological adjustment to medical illness applied to cancer patients.

The interrater reliability and validity of brief interview rated measures of psychosocial adjustment were examined in four sequential studies. A total of 25 videotaped interviews with cancer patients were rated by 105 social workers, nurses, physicians, and specialists in psychosocial oncology. The Rating of Psychosocial Function (RPF), Coping Adequacy Rating (CAR), and Global Adjustment to Illness Scale (GAIS) were used by various rating groups with an indication of interrater agreement. Agreement on ratings was not influenced by the length of interview (15 vs. 30 minutes) but appeared to the affected by the structure of the interview and profession of the raters. All three instruments showed a measure of matching with clinical impressions in addition to demonstrating a measure of both convergent and divergent construct validation. The GAIS was chosen as most adequately reflecting their clinical impression by a majority of raters. With a degree of training, any of the three instruments could be used to assess psychosocial adjustment with some measure of confidence in the validity of the rating.

Clinical trials in psychosocial medicine: methodologic and statistical considerations. Part I. Introduction.

Psychosocial oncology is defined as a newly developing field which requires its own methodology for measuring the importance of psychologic and social factors for cancer patients, their families, and involved health professionals. As with all new areas of research, there must be a systematic approach once clinical observations and initial hypotheses have been made. The science for such an approach has been slow to develop because of the complexities of finding and testing the appropriate instruments for identifying and quantifying variables before trying to improve the patient's adjustment. In order to facilitate this process, a five-center collaborative group has been formed. Among its first tasks are the selection and testing of screening instruments.

The dying patient.

Dying is again being recognized as a natural phase of life for which we spend a lifetime preparing. There are times during life when it seems least appropriate and most difficult to accept dying, as in childhood. It is important to recognize that we go through life acquiring and losing significant objects in our quest for greater self-esteem and in our preparing for dying. To approach the awareness of dying as a life crisis which allows a new awareness towards self and reality makes the process of dying not only challenging but worth the living. Health care professionals must guard against trying to mold patients into their reality and thus meeting their own needs and not the patients'. Specific guidelines for the support of dying called Comfort Care Only shift the therapeutic focus from a preoccupation with the patient's disease to the broader human concerns and a sharing of the experience which is as important for the surviving as it is for the dying.

A survey of psychotropic drug prescriptions in an oncology population.

The present study examined the prescription practices concerning psychotropic drugs in 5 major oncology centers over a 6 month period. During the survey period 1579 patients were admitted to the collaborating institutions, and 51% of them were prescribed at least one psychotropic medication. Hypnotics were the most frequently prescribed drugs, accounting for 48% of total prescriptions, followed by anti-psychotics at 26% and anti-anxiety agents at 25%. Anti-depressant drugs accounted for only 1% of psychotropic prescriptions. Analysis of prescription rationales revealed that 44% of the psychotropic prescriptions were written for sleep, while 25% were given for nausea and vomiting; approximately 17% were attributed to psychological distress, and 12% were associated with diagnostic medical procedures. The overall rate of prescription was approximately 2 psychotropic drugs per patient per admission, with only 2% of prescriptions resulting in chart-documented side effects. At the level of individual compounds, 3 distinct drugs accounted for 72% of total prescriptions--flurazepam (33%), prochlorperazine (21%), and diazepam (17%).

Psychological aspects of anorexia: areas for study.

Anorexia and weight loss are frequently the first manifestations of cancer. Although psychological reasons are frequently included as a partial explanation for loss of appetite and weight in the cancer patient, there have been no systematic studies which establish the nature of this relationship. It is proposed that anorexia and cachexia are at times somatic consequences of the cancer patient's beliefs and attitudes about their disease and its treatments. The inability to overcome a sense of hopelessness leads to an adaptive biological reaction called conservation-withdrawal. The effects of the reaction of disengagement and inactivity in relation to the external world which includes external nutriment may be constructive or destructive depending on when it is experienced and the length of time the reaction continues. How this reaction is initiated and mediated biologically and how it may be related to and can be reversed by a shift in motivation are questions of great importance.

A simple technique for increasing cancer patients knowledge of informed consent to treatment.

Seventy-seven sequential patients referred to a radiation oncology clinic for treatment of malignant neoplasms were tested for their immediate recall of information presented, recorded, and signed on informed consent documents. An experimental group of 40 patients were given the intervention of taking the completed form home before signing. Results support the usefulness of the intervention. The experimental patients were found to possess greater information than the 37 patients who signed the form after the usual clinic procedure in virtually every area required of informed consent. The most significant gains were made in patients' understanding of proposed treatment procedures and appropriate treatment alternatives. Women recalled more information relevant to informed consent than did men. Results also indicated a tendency for younger patients to recall more informed consent information than older patients.