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 cancer among patients, their families, and oncology staff, but also to study the influence of psychosocial issues on patients's quality of life or survival.

Routine Activities 
The Psychiatry Division consists of five adjunct psychiatrists, one staff clinical psychologist, and one clinical resident. The main clinical practice involves psychiatric consultation to assess and deal appropriately with the emotional distress and other psychological problems of cancer patients who are referred by attending physicians. The consultation data are shown in the Table. Psychiatric diagnosis was based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) criteria. In 2002, total of 359 referrals (7% increase over 2001) were made for the psychiatric consultation. These referrals included 10 cancer patients' family members and 7 oncology staff members. Among them 73% were inpatients. The most common psychiatric diagnosis was major depression (34%) followed by adjustment disorders (26%) and delirium (11%). The most common cancer site was lung, and the next was head and neck. More than 60% of the referrals had recurrent or metastatic cancer. The most common reason for psychiatric consultation was depression (32%), followed by anxiety/fear (26%) and psychiatric evaluation (23%). 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 all currently referred cases carefully. Also, we have clinical rounds for difficult cases every Monday and Friday evening. We have multi-center joint clinical conference involving the National Cancer Center Hospital East, National Cancer Center Hospital, and Shikoku Cancer Center Hospital that was started in 2001 on every Thursday evening, and Kyushu Cancer Center Hospital joined the conference in 2002.
A research conference is held every Monday and Thursday evening for discussing and planning protocols and a journal club is held every Wednesday evening for important papers with all the members of our division, Psycho-Oncology Division in NCCRIE and Psychiatry Division of NCCH.

New Developments 2002
1. Predictive factors for suicidal ideation in patients with unresectable lung cancer
The purpose of the present study was to investigate the prevalence and predictive factors of suicidal ideation in patients with unresectable lung cancer in a follow-up setting. Patients with newly diagnosed unresectable non-small cell lung cancer participated in this study. The patients' suicidal ideation was assessed 6 months after disclosure of the cancer diagnosis to the patients. Predictive factors for suicidal ideation were investigated by assessing a broad range of biomedical and psychosocial factors between the time of disclosure and start of cancer therapy (baseline) and 6 months after disclosure of the cancer diagnosis (follow-up). Although strong suicidal ideation was rare in this population, 13 (15%) of the 89 subjects who completed the baseline and follow-up ratings had some degree of suicidal ideation at 6 months after disclosure of the cancer diagnosis. Multivariate analysis indicated that pain at baseline and new development of depressive disorder were the final significant predictive factors. Suicidal ideation in unresectable lung cancer patients should not be neglected, because it is not rare, and comprehensive care consisting at least earlier pain management and appropriate psychiatric intervention is indispensable to preventing subsequent suicidal ideation.
2. Clinical factors associated with suicidality in cancer patients
We investigated the clinical factors associated with suicidality in cancer patients by analyzing the consultation data of patients referred to the Psychiatry Division. Of 1713 psychiatric referrals, 62 (3.6%) were related to suicidality, including 44 cases with suicidal ideation, 10 suicide attempts, and 8 cases who had requested euthanasia and/or continuous sedation. Most of the patients suffered from physical distress and/or psychiatric disorders. The results of a multivariate analysis comparing cancer patients with a psychiatric referral related to suicidality and those referred for other reasons indicated that impaired physical functioning and major depression were significant associated factors. Our findings suggest that early detection and appropriate management of major depression, and comprehensive care improving physical functioning may help to prevent suicide and manage suicidality in Japanese cancer patients.
3. Efficacy of methylphenidate for fatigue in advanced cancer patients: a preliminary study
The aim of this study was to examine the efficacy of methylphenidate for fatigue in advanced cancer patients. We used methylphenidate for patients with advanced cancer. Severity of fatigue was assessed using the visual analogue scale (VAS) pre- and post-treatment. A total of 14 patients completed the study. Results indicated that fatigue was significantly improved after administration of methylphenidate. Our findings suggest that methylphenidate may be useful for alleviating fatigue in advanced cancer patients.
4. Cancer-related intrusive thoughts as an indicator of poor psychological adjustment at 3 or more years after breast surgery: A preliminary study
The aim of this preliminary study was to examine the possibility of using cancer-related intrusive thoughts (CITs) as an indicator of psychological distress and adjustment after breast surgery. A consecutive series of ambulatory breast cancer survivors at 3 or more years after surgery completed the interview for CITs and several questionnaires to measure psychological distress and/or adjustment. The SCID identified a history of CITs in 34 (46%) of the 74 participants. Multivariate analysis inidicated that subjects with a history of CITs showed significantly higher levels of anxious preoccupation, a kind of poor coping with cancer. The results indicated that CITs might be useful for indicating poor psychological adjustment in patients at 3 or more years after breast surgery.
5. Ongoing protocol study
A brief screening instrument for adjustment disorders and/or major depression among cancer patkents is now developed. Feasibility study on treatment algorithm for major depression among advanced cancer patients is ongoing. Also, studies on individually tailored multi-faceted psychiatric intervention on common psychiatric disorders in patients with recurrent breast cancer are now ongoing.

Y. UCHITOMI

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