The finding:
Mothers, but not fathers, of children diagnosed with cancer, have a 23% higher risk of hospital contact for any psychiatric disorder. Individual risk factors included employment within one year of children’s diagnosis, age younger than 30, lower education, and immigrant status. Mothers of children diagnosed with leukemia and CNS tumors, as well as younger child’s age at diagnosis, were at a higher risk. Only fathers of children diagnosed with lymphoid leukemia, CNS tumor, and a bone tumor or soft tissue sarcoma were at increased risk of psychiatric disorders in the diagnostic period from 1982 to 1999.
Strength and weaknesses:
This study derives its principal strength from its large sample size with over 12,000 case parents and over 123,000 control parents. The study was vastly inclusive, encompassing contacts of patients with any psychiatric encounter. Additionally, researchers compared mothers and fathers separately and stratified for cancer type, inpatient and outpatient psychiatric contacts, and meaningful time windows concerning the child’s diagnosis date. Finally, the risk analysis tried to account for advances in cancer care that could have impacted outcomes. The results must be examined in light of increased surveillance for psychiatric distress in parents of children with cancer compared to controls, potential misclassification on the medical record, and lack of control for pre-existing psychiatric diagnoses.
Relevance:
Having a child diagnosed with cancer is a calamitous event for any family. It impacts family routines, responsibilities, finances, and parental and marital dynamics. Unfortunately, studies on this topic are small and focus on specific psychiatric diagnoses and most prominently on mothers. This large population-based study provides a better framework for C-L Psychiatrists to identify parents at risk for psychiatric distress and argues for developing programs that focus on supporting parents during child medical crises. Recognizing and addressing the mental health needs of this population can mitigate the negative impact on health problems and the associated costs related to healthcare utilization, productivity loss, and sick leave.
Type of study (EBM guide):
Cohort study
PUBLICATION #3 — Psychooncology
Use of psychotropic drugs among older patients with bladder cancer in the United States.
Usama Jazzar, Cristiane D Bergerot, Yong Shan, Christopher J D Wallis, Stephen J Freedland, Ashish M Kamat, Douglas S Tyler, Jacques Baillargeon, Yong-Fang Kuo, Zachary Klaassen, Stephen B Williams
Abstract: Psychooncology. 2021 Jun;30(6):832-843. doi: 10.1002/pon.5641. Epub 2021 Feb 20.
Objective:
Older patients diagnosed with cancer are at increased risk of physical and emotional distress; however, prescription utilization patterns largely remain to be elucidated. Our objective was to comprehensively assess prescription patterns and predictors in older patients with bladder cancer.
Methods:
A total of 10,516 older patients diagnosed with clinical stage T1-T4a, N0, M0 bladder urothelial carcinoma from 1 January 2008 to 31 December 2012 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare were analyzed. We used multivariable analysis to determine predictors associated with psychotropic prescription rates (one or more). Medication possession ratio (MPR) was used as an index to measure adherence in intervals of 3 months, 6 months, 1 year, and 2 years. Evaluation of psychotropic prescribing patterns and adherence across different drugs and demographic factors was done.
Results:
Of the 10,516 older patients, 5621 (53%) were prescribed psychotropic drugs following cancer diagnosis. Overall, 3972 (38%) patients had previous psychotropic prescriptions prior to cancer diagnosis, and these patients were much more likely to receive a post-cancer diagnosis prescription. Prescription rates for psychotropic medications were higher among patients with higher stage BC (p < 0.001). Gamma aminobutyric acid modulators/stimulators and serotonin reuptake inhibitors/stimulators were the highest prescribed psychotropic drugs in 21% of all patients. Adherence for all drugs was 32% at 3 months and continued to decrease over time.
Conclusion:
Over half of the patients received psychotropic prescriptions within 2 years of their cancer diagnosis. Given the chronicity of psychiatric disorders with observed significantly low adherence to medications that warrants an emphasis on prolonged patient monitoring and further investigation.
Annotation
The finding:
Among patients with bladder cancer, the majority (53%) were prescribed one or more psychiatric drugs following their diagnosis. Stage of disease was associated with increased rate of prescribing (except for stage IV). 37% of patients were prescribed psychiatric drugs prior to the diagnosis, and this was also the strongest predictor of being prescribed psychiatric drugs following the diagnosis. Sedative/hypnotics and antidepressants were most commonly prescribed, with 21% of patients prescribed each. Adherence rates were generally low (around one-third at 3-months post diagnosis) and continued to decrease over time.
Strength and weaknesses:
The study’s main strengths are that it pulled data from a large American cancer database (SEER) and used neuroscience-based nomenclature (e.g., serotonin reuptake inhibitor) to classify medications. The limitations of this type of study pertain to its methodology. It is a cohort study. Although the authors analyzed a large dataset, we are unable to make conclusions about causality. Close to 90% of the cohort identified as white (non-Hispanic white); while this mirrors SEER data for bladder cancer, it also potentially limits generalizability to non-white populations.
Relevance:
There is a dearth of literature on the rates of psychiatric drug prescription in cancer patients in general, but more specifically in bladder cancer. The findings suggest that more attention must be paid to psychiatric needs of patients with bladder cancer. While the rate of prescribing seems high, the non-adherence may have a number of different implications: perhaps there is over-prescribing of psychiatric drugs initially; perhaps there is a need to better target who is prescribed drugs versus non-pharmacologic treatments; perhaps the rate of prescribing is appropriate but more attention is needed to help patients adhere to medications.
Type of study (EBM guide):
Cohort study
Also of interest – PUBLICATION #4 — Psychooncology
The Impact of an Unconventional Elective in Narrative Medicine and Pediatric Psycho-oncology on Humanism in Medical Students.
F Jeffrey Lorenz, Matthew C Darok, Lisa Ho, Maria S Holstrom-Mercader, Andrew S Freiberg, Cheryl A Dellasega
Abstract: J Cancer Educ. 2021 May 31. doi: 10.1007/s13187-021-02029-8. Online ahead of print.
Over the course of medical school, students’ optimism and hopefulness often devolve into a cynical view of medicine that continues throughout clinical rotations and beyond (Neumann et al., Acad Med 86(8):996–1009, 2011). Here, we present a qualitative evaluation of a novel immersive elective in pediatric psycho-oncology coupled with narrative medicine and its impact on students. Participants were third- and fourth-year medical students who were relieved of traditional clinical duties. Alternatively, they shadowed pediatric cancer patients, keeping narrative journals of their observations and insights. A trained team of pre-clinical medical students and faculty conducted a retrospective analysis of 120 journals written between 2008 and 2019. They compared recurring concepts to assess how blending experiential learning and reflective writing influenced the attitudes and behaviors of students. Consistent themes emerged related to developing a rich understanding of patient experiences, a humanistic appreciation of the context of illness, the ability to meaningfully reflect on insights to critically ill children, and an appreciation for the unique learning opportunity. Additionally, families expressed gratitude for the students’ attentiveness to their emotional needs. By the conclusion of the elective, most students discovered that they had reignited their intrinsic empathic behaviors and were provided with beneficial insights that they believed would continue into future rotations. Experiential teaching methods paired with narrative reflection may be a valuable and therapeutic tool to learn the intricacies of the patient perspective, with the potential to enhance humanism in students during a critical time in their medical training when empathy tends to drift. Longitudinal and quantitative studies are warranted to better understand the degree and duration of specific benefits.
Annotation (unstructured)
Annotation (unstructured):
The authors describe a medical elective in narrative medicine whereby medical students journaled their reflections after time spent shadowing pediatric psycho-oncology patients. The authors encouraged meaningful reflection as a tool to help students connect or reconnect with the inherent empathy that led them towards medicine in the first place. On the surface, this article chronicles an interesting and unconventional elective which any academic clinician in psycho-oncology ought to consider offering. More deeply, though, and read through the lens of a world stricken by COVID, it serves to inspire, as a recipe to reignite our own empathic behaviors at a time in history when this is deeply needed.
Type of study (EBM guide):
Other (enter a free text description on the document)