“Health and disease are determined by dynamic interactions among biological, psychological, behavioral and social factors.” – US Research Council Committee
Biological: Severe pain of the 55 years old family father diagnosed with gastrointestinal cancer causes the patient to take more rests and absence from work. Chemotherapy and further medication are planned to treat cancer. Genetically the man was tested to not have the disposition to develop chronic pain.
Psychological: According to the patient’s wife, new behavior since diagnosis shows prolonged states of anger and depression. In initial consultations with the doctor, the patient reported his psychological state as stable.
Social: The patient’s concern is the continuation of his job, the wish to spend family time, and private financial matters. The patient is skeptic about the possibilities of oncology and wishes full transparency and own decision right regarding the treatment plan.
Person-centric and holistic treatment
(Neuropathological) Pain management: Non-pharmacological methods can work for less pain perception, and antidepressant can treat chronic pain. As suggested by Kurita (2015), the goal is to intervene with the double purpose of responding to the patient’s depression and to create a positive treatment effect for reducing pain at the same time (p. 632).
Excourse: For more details related to antidepressants (ADs) used for pain treatment, see below (bottom of the article).
Biopsychosocial screening: Indirectly reported anger and depression prompted the sensitive physician and his multi-disciplinary team to evaluate cancer-related emotional distress. Loscalzo, Clark, Pal, and Pir (n.d) confirm that biopsychosocial screening is a necessity as part of cancer care. Loscalzo et al. (n.d) also tell that screening positively impacts not only emotional well-being but also other treatment aspects such as pain. The multidisciplinary NCCN ‘Distress Thermometer’ is a tool to perform the patient-centric screening (p. 415). As a result, supportive care is designed to meet treatment’s and patient’s needs, e.g., by referrals to further experts such as physiotherapists and psychologists.
Psychological and spiritual support: Simple behavioral or cognitive behavioral therapy (CBT) shall help the patient to pursue his goals in a feasible way. Achieving realistic goals at work and in the family environment is reinforcing patient’s self-worth and may have a positive effect on anger and depression. Psychological and spiritual expertise may help to cope with the situation and in how to re-assess life. Improved mental health may positively affect the effectiveness of the overall treatment and the well-being of the patient and his entourage. Em Arpawong, Milam, Richeimer, Weinstein, and Elghamrawy (2013) are underlining that a positive Quality of Life (also in the context of post-traumatic growth (PTG)) is related to mental health (p. 406).
Environmental assistance: Biopsychosocial integration and education of professionals, the information, and involvement of the patient’s environment such as work colleagues and family members shall provide the basis for the effective and efficient provision of financial and practical assistance in the course of the treatment as required. For close friends and family members, bereavement counseling may constitute a further need for support.
A biopsychosocial approach shouldn’t be confined to the patient; all in the sense of Engel’s (1980) vision that “the most obvious fact of medicine is that it is a human discipline, one involving role- and task-defined activities of two or more people” (p. 535).
Excourse: Antidepressants (ADs) used for pain treatment
Shinde, Gordon, Sharma, Gross, and Davis (2014) are confirming positive evidence for the favorable use of ADs for the treatment of pain and, although less studied so far, for cancer pain (p. 696). On the other side, there seems to be no standard guideline regarding what AD to be used in what doses for what type of cancer pain. A patient’s situation needs to be assessed in detail. The use of ADs in combination with opioids needs to be ‘calibrated’ to the level of optimal dose relation between the AD and the opium in order to reduce side effects, and the maximum pain relief possible; this process is called titration as described by Rana, Ahmed, Kumar, Chaudhary, Khurana, and Mishra (2011, p. 3).
There are nevertheless some known factors regarding side effects of ADs. For example, some AD drugs are not recommended for the treatment of older persons because of the side effects such as fatigue, apathy, and cognitive impairment (Tarleton, 2016). There is, however, evidence that a newer generation of AD drugs comes with fewer side effects. Some of those may lead to gastrointestinal bleeding though (Tarleton, 2016, p. 129), what in the presented case study of gastrointestinal cancer would be especially contra-productive. Also, the AD drug substance Serotonin is found to affect the gut-brain signaling. Interestingly, a high number of patients with depression do have intestinal problems (Tarleton, 2016, p. 131). In that case, the depression of the example patient could be not only a consequence of pain and cancer diagnosis related psychological and social distress, but stemming (also) directly from these physiological guts problems. Consequently, the treatment with ADs with potential impact on cancer affected and depression causing gastrointestinal area poses an additional risk and should be avoided.
Although the use of ADs for complementary pain treatment makes sense for depressive patients, there may be still further and different ADs required for addressing the depression itself. Other factors to consider are the timing of the use or change of treatment strategies, dis-continuation problematics because too immediate cessation of medication may cause side effects too, and drug combination risks. The latter is described by Lussier, Huskey, and Portenoy (2004) as “risk for drug-drug interactions” (p. 585).
In the sense of a person-centric treatment, the responsible doctor shall inform the patient of possible alternative courses of treatment and related risks for side effects. Finally, only the patient can take the decision for accepting one side effect instead of another, because more severe side effects with a disabling character may challenge the psychological well-being of the patient.
Em Arpawong, T. )., Milam, J. )., Richeimer, S. )., Weinstein, F. )., & Elghamrawy, A. ). (2013). Posttraumatic growth, quality of life, and treatment symptoms among cancer chemotherapy outpatients. Health Psychology, 32(4), 397-408. doi:10.1037/a0028223
Engel, G. L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137,535-544.
Kurita, G. P., & Sjøgren, P. (2015). Pain management in cancer survivorship. Acta Oncologica, 54(5), 629-634. doi:10.3109/0284186X.2014.996662
Loscalzo, M., Clark, K., Pal, S., & Pirl, W. (n.d). Role of Biopsychosocial Screening in Cancer Care. Cancer Journal, 19(5), 414-420.
Lussier, D., Huskey, A., & Portenoy, R. (2004). Adjuvant analgesics in cancer pain management. Oncologist, 9(5), 571-591.
Rana, S. S., Ahmed, A., Kumar, V., Chaudhary, P. K., Khurana, D., & Mishra, S. (2011). Successful Management of a Difficult Cancer Pain Patient by Appropriate Adjuvant and Morphine Titration. Indian Journal Of Palliative Care, 17(2), 162-165. doi:10.4103/0973-1075.84541
Shinde, S., Gordon, P., Sharma, P., Gross, J., & Davis, M. (2014). Use of non-opioid analgesics as adjuvants to opioid analgesia for cancer pain management in an inpatient palliative unit: does this improve pain control and reduce opioid requirements?. Supportive Care In Cancer, doi:10.1007/s00520-014-2415-9
Tarleton, E. K., Kennedy, A. G., & Daley, C. (2016). Educational paper: Primer for nutritionists: Managing the side effects of antidepressants. Clinical Nutrition ESPEN, 15126-133. doi:10.1016/j.clnesp.2016.05.004