Psychiatry Service

Introduction
The Psychiatry Division of the National Cancer Center Hospital East was established in July 1996. This Division has been designed not only to manage and alleviate the emotional distress due to cancerous conditions among patients, their families, and oncology staff, but also to study the influence of psychosocial issues on patients' quality of life or survival.

Routine Activities　
The Division consists of five adjunct psychiatrists, one staff clinical psychologist, and two residents. The main clinical practice involves psychiatric consultation to assess and treat the emotional distress and other psychological problems of cancer patients referred by attending physicians. Psychiatric diagnosis was based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) criteria. In 2001, a total of 334 referrals (10% up to 2000) underwent consultation. These included 12 cancer patientsi family members and 9 oncology staff members. Among them 73% were inpatients; the most common was adjustment disorders (25%) followed by major depression (20%) and delirium (20%). As to cancer site the most common was lung, and the next was head and neck. More than a half of the referrals had recurrent or metastatic disease. As to reason for psychiatric consultation psychiatric evaluation (29%) was the commonest, followed by depression (20%) and anxiety/fear (19%). Of all the referrals, more than half patients had pain.
We had a liaison rounds for the newly referred inpatients on every Wednesday afternoon with the staff from the Psycho-Oncology Division, National Cancer Center Research Institute East. Before the rounds, we discuss on all currently referred cases carefully. Also, we have clinical rounds for troublesome cases on every Monday and Friday evening. In 2001, multi-center conference involving the NCCHE, National Cancer Center Hospital, and Shikoku Cancer Center Hospital was started on every Thursday evening.
A research conference is held every Tuesday evening, for discussing on planning protocols and holding a journal club for important papers with all the members of our division, Psycho-Oncology Division in NCCRIE and Psychiatry Division of NCCH.

New Developments
1. Group psychotherapy for cancer patients
In November 2001, we introduced a group psychotherapy program involving patient education, enhancing mutual support, and encouragement of adaptive coping skills for the patients with early-stage breast cancer after surgery.
2. Psychiatric disorders in unresectable non-small cell lung cancer patients
This study investigated prevalence of psychiatric disorders, longitudinal course of psychological distress,and associated and predictive factors for this distress in unresectable non-small cell lung cancer patients.Consecutive 129 patients participated in the study. Psychiatric assessment was conducted using the StructuredClinical Interview for DSM-IIIR, com-paring the state at the initial anti-cancer treatment (baseline) with six months after the treatment (follow-up). The commonest psychiatric disorder was nicotine dependence (67%),followed by adjustment disorders (14%), alcohol dependence (13%), and major depression (5%) at baseline. At follow-up, adjustment disorders were diagnosed in 17% of the subjects and major depression in 3%. One fourth of the subjects who suffered from psychological distress at baseline continued it at the follow-up. Multivariate analysis revealed that younger age and pain are significantly associated with distress at baseline. Only selfreported anxiety at the baseline could predict consequent psychological distress. Substance dependence and depressive disorders are common psychiatric disorders in these patients. Although the cancerous conditions are usually progressive, psychological distress does not appear to increase in its clinical course. Pain management is essential for alleviating psychological distress of the patients and anxiety symptom may be a potential indicator of subsequent psychological distress.
3. Desire for an early death in depressive cancer patients
We investigated the background differences between cancer patients suffering from major depression with and without suicidal ideation by analyzing the consultation data in our division. Of the 1721 referred patients, 220 (12.8%) had a diagnosis of major depression, and of whom 113 (51.4%) had suicidal ideation. Logistic regression analysis indicated that poor physical functioning and severe depression are significant risk factors.
4. Psychiatric disorders in cancer patients
We investigated the characteristics, reason for undergoing psychiatric consultation, and psychiatric diagnosis of cancer patients by analyzing the database of those referred to the psychiatry divisions of NCCH and NCCHE. Of a total of 1721 referrals 78% was inpatients. Lung cancer (19%) was the commonest disease, followed by breast (13%) and head and neck cancers (10%). More than half of the patients had recurrent and/or metastatic disease, and 60% of them had pain. The commonest reason for the consultation was psychiatric evaluation (35%), followed by sleep disorders (19%), anxiety or fear (18%), and depression (18%). Regarding the psychiatric diagnosis, adjustment disorders were the commonest (34%), followed by delirium (17%) and major depression (14%). The diagnosis of cancer had been disclosed to more than 99% of the patients. The spectrum of psychiatric disorders observed in our patients was similar to that in the Western countries where the cancer diagnosis is disclosed.
5. Ongoing protocol study
Studies on the desire for death in terminally ill patients and the effectiveness of tailored psychiatric intervention for psychiatric disorders in patients with recurrent breast cancer are now ongoing.

Y. UCHITOMI

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