Psycho-oncology — structured clinical viva · Psych Vivas

Prompt

You are the CL psychiatry registrar. Oncology requests review of a 61-year-old man with metastatic lung cancer: low mood for 6 weeks, poor oral intake, and a new wish that 'it would be easier if I died soon.' He started dexamethasone 5 days ago for brain oedema and has become irritable and sleepless. Staff ask for 'haloperidol QID for confusion at night' and whether meaning-centred therapy is 'just counselling.' Structure your approach across syndrome map, risk, SMaRT evidence, steroid effects, Agar limits, interactions if he were on tamoxifen, and capacity/end-of-life issues.

Interpretation

Reveal interpretation

Open with a syndrome map, not a single label. Hold major depression, demoralisation, steroid neurotoxicity, and possible nocturnal delirium as concurrent possibilities in advanced lung cancer.[5]

Risk first. Passive or active wish to die after cancer requires structured suicide assessment; Fang data support elevated risk after diagnosis — safety planning, means, observation intensity, and treatable depression/delirium work-up.[6]

Depression care. Name SMaRT Oncology-2 (mixed cancers) and SMaRT Oncology-3 (lung/poor prognosis) collaborative care for major depression outcomes.[1][2]

Steroids. Link sleepless irritability to dexamethasone; reduce if safe; short-term safety pharmacology only if danger.[5]

Reject QID haloperidol as delirium cure. Cite Agar: antipsychotics worse than placebo for palliative delirium symptoms — non-drug care and cause treatment first.[3]

If tamoxifen stem appears. Avoid paroxetine/fluoxetine (Kelly).[4]

Therapies. Meaning-centred psychotherapy is a structured, trial-supported intervention for advanced cancer well-being — not vague reassurance.[7] Early palliative care improves QoL/mood in metastatic NSCLC (Temel).[8]

Capacity. Decision-specific for treatment choices and end-of-life plans; reassess after optimising delirium/steroid/mood factors.[5]

Escalating questions (model points)

Expect: definition of psycho-oncology and distress vs disorder; Mitchell-level awareness that mood/anxiety/adjustment problems are common; SMaRT collaborative care components; antidepressant choice with interaction literacy; steroid spectrum; CAM delirium; Agar result; Fang suicide window; Breitbart MCP; Temel early palliative care; capacity principles under local law; demoralisation phenomenology (Kissane/Clarke).[1][3][4][6][7][8]

Key points

References

[1]Sharpe M, Walker J, Holm Hansen C, et al. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial Lancet, 2014.PMID 25175478
[2]Walker J, Hansen CH, Martin P, et al. Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer Lancet Oncol, 2014.PMID 25175097
[3]Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial JAMA Intern Med, 2017.PMID 27918778
[4]Kelly CM, Juurlink DN, Gomes T, et al. Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study BMJ, 2010.PMID 20142325
[5]Warrington TP, Bostwick JM Psychiatric adverse effects of corticosteroids Mayo Clin Proc, 2006.PMID 17036562
[6]Fang F, Fall K, Mittleman MA, et al. Suicide and cardiovascular death after a cancer diagnosis N Engl J Med, 2012.PMID 22475594
[7]Breitbart W, Rosenfeld B, Pessin H, et al. Meaning-centered group psychotherapy: an effective intervention for improving psychological well-being in patients with advanced cancer J Clin Oncol, 2015.PMID 25646186
[8]Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer N Engl J Med, 2010.PMID 20818875

Interpretation

Reveal interpretation

Open with a syndrome map, not a single label. Hold major depression, demoralisation, steroid neurotoxicity, and possible nocturnal delirium as concurrent possibilities in advanced lung cancer.[5]

Depression care. Name SMaRT Oncology-2 (mixed cancers) and SMaRT Oncology-3 (lung/poor prognosis) collaborative care for major depression outcomes.[1][2]

Steroids. Link sleepless irritability to dexamethasone; reduce if safe; short-term safety pharmacology only if danger.[5]

Reject QID haloperidol as delirium cure. Cite Agar: antipsychotics worse than placebo for palliative delirium symptoms — non-drug care and cause treatment first.[3]

If tamoxifen stem appears. Avoid paroxetine/fluoxetine (Kelly).[4]

Capacity. Decision-specific for treatment choices and end-of-life plans; reassess after optimising delirium/steroid/mood factors.[5]

Escalating questions (model points)

Key points

References

[1]Sharpe M, Walker J, Holm Hansen C, et al. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial Lancet, 2014.PMID 25175478
[2]Walker J, Hansen CH, Martin P, et al. Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer Lancet Oncol, 2014.PMID 25175097
[3]Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial JAMA Intern Med, 2017.PMID 27918778
[4]Kelly CM, Juurlink DN, Gomes T, et al. Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study BMJ, 2010.PMID 20142325
[5]Warrington TP, Bostwick JM Psychiatric adverse effects of corticosteroids Mayo Clin Proc, 2006.PMID 17036562
[6]Fang F, Fall K, Mittleman MA, et al. Suicide and cardiovascular death after a cancer diagnosis N Engl J Med, 2012.PMID 22475594
[7]Breitbart W, Rosenfeld B, Pessin H, et al. Meaning-centered group psychotherapy: an effective intervention for improving psychological well-being in patients with advanced cancer J Clin Oncol, 2015.PMID 25646186
[8]Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer N Engl J Med, 2010.PMID 20818875