Neoplastic diseases in pediatric patients are one of nature’s terrible experiments and pediatric oncology is a privileged setting for observing many phenomena that have yet to be understood, relating for instance to psychological adaptation to the trauma of disease.
Severe disease places a heavy burden on an individual’s capacity for psychological adaptation, particularly in such a crucial period as adolescence as an individual develops their sense of identity, relationships and self-esteem. Working in the field of pediatric oncology gives us a chance to observe how our patients develop into adults, including from a psychological standpoint.
Treating the emotional distress of our patients during and after treatment poses particular problems relating first of all to identifying conditions of mental suffering – namely the moment of the diagnosis – and then treating these conditions using the most appropriate methods. From a diagnostic standpoint, it is important to mention that specialists in pediatric oncology rarely apply diagnostic codes according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV TR Citation[1]. This may be partially justified by the fact that research into mental health in pediatric oncology has shown that most cancer patients under treatment as well as cancer survivors do not have frank psychiatric disorders Citation[2]. These studies mainly investigated the areas of anxiety and mood disorders, paying much less attention to aspects of personality and adaptation Citation[3], partly because they used assessment tools designed for use by psychiatrists Citation[4]. There has been some change in the approach taken in recent years, now that the role of certain aspects of post-traumatic stress disorder have been investigated in situations of oncological disease Citation[5,6]. It seems evident nowadays that assessing quality of life by measuring symptoms alone is too simplistic now that, among other things, new systems for classifying mental diseases have been proposed, such as the Psychodynamic Diagnostic Manual (PDM), which emphasizes the relevance of personality and psychic functioning alongside the diagnosis of psychiatric disorders Citation[7]. In point of fact, although the PDM was introduced some years ago, and was met with interest in the world of clinical psychology, its impact on research in pediatric oncology has been extremely limited. This may be due partly to the fact that the PDM provides an interesting theoretical evaluation, but the tools for its clinical application are still scanty.
A second fundamental aspect concerns therapy. The challenge for today’s clinicians is to develop a stronger integration between methods of care for psychiatric disorders. Psychiatry and psychopharmacology on the one hand, and clinical psychology and psychotherapy on the other, offer two different perspectives for interpreting psychological suffering, and consequently also for treating it. In pediatric oncology, there is generally a tendency to manage most conditions of emotional discomfort using psychological and relational tools (psychotherapy), whereas symptoms of anxiety and mood disorders (also secondary to chemotherapy), agitation (also relating to steroid therapy), aggression and apathy are signs that psychopharmacological consultation may be warranted.
On the matter of psychopharmacological treatments in pediatric oncology, there are several issues to consider. The first concerns the criteria for selecting the type of psychopharmacological intervention: texts on psychopharmacology and guidelines for adult patients only partially address the choice of therapy Citation[8,9]. In clinical practice, benzodiazepines are commonly used to treat anxiety, insomnia, agitation and aggression. To a lesser degree, neuroleptics are used for conditions of anguish, confusion, agitation and aggression. A less routine use is made of antidepressants for the treatment of mood disorders. Another problem concerns the treatment of patients who have psychiatric disorders before developing a neoplastic disease: a better understanding of the pharmacological interactions and of the nature of such patients’ psychopharmacological treatments would enable a better, safer use of the other medication they receive. We need a better understanding of the use of antidepressants in adolescents with cancer, also in view of the suicide risk, and the same applies to the pharmacological treatments for the, albeit rare, cases of aggression, which can pose important clinical management problems. There is also ample room for improvement in our understanding of the link between symptoms of depression, fatigue, the neurotoxicity of chemotherapeutic drugs and immune system issues.
Then there is the matter of how to integrate psychopharmacological treatments with psychotherapy. The problem of prescribing psychopharmacological medication for patients of developmental age has been debated for years, and is also burdened by ideological prejudice. Some psychotherapy traditions were against providing any concomitant pharmacological treatment for fear that this would interfere with the progress and success of the psychotherapy. By the 1970s there were already reports to the effect that associating drugs with psychotherapy does no harm to patients Citation[10]. There is no earthly reason why a modern approach should continue to see any conflict between drugs and psychotherapy; it is absolutely necessary to use them both in synergy Citation[11]. The picture is made even more complex by the persistent paucity of literature orienting the choice of action to take in situations where emotional distress or behavioral disorders are seen in patients with neoplastic disease. One has the impression that even in pediatric oncology – a field that pioneered the provision of psychological support for cancer patients – the integration between psychotherapy and psychopharmacology is still unsatisfactory.
At most pediatric oncology centers in Italy, for instance, the staff include psychologists; however, they are not involved in prescribing any psychopharmacological treatments. In the rare cases where such treatments are used, they are managed by outside consultants, and they are only made available at a few centers, and on an ad hoc basis. Reliance on consultant psychiatrists from outside the department is one of the factors that can interfere with the chances of developing genuinely integrated patient care. In addition, consultations on mental health in pediatrics are generally conducted and oriented according to conventions adopted at a given department, and such consultations consequently vary considerably in terms of the operators’ training, reference theories and objectives, the duration of the consultation and the methods used. This diversity of approach is probably one of the reasons for the paucity of studies on the psychosocial treatment of severe diseases in individuals of pediatric age Citation[12]. Integrated treatment approaches are not always on university curricula or part of the operators’ professional training courses.
Many other aspects relating to the integration of the various treatment options remain to be perfected. Managing emotional malaise in adolescent patients is still by no means easy. The challenge of any intervention on mental health in pediatric oncology, and for adolescent patients in particular, is to arrive at the best possible treatment of their emotional symptoms using all available resources. It is clear that mood disorders cannot always be handled with antidepressants, because sadness can also be a ‘healthy’ way of adapting and an inevitable part of their process of healing. The course of severe disease involves a number of resources, experiences and relations, and the related psychological symptoms are not, in themselves, something to be eliminated at all costs. There are nonetheless certain cases in which psychopharmacological therapy is appropriate.
In conclusion, it is useful to remember that general theoretical considerations on the definitions of disease and suffering can draw from experience gained in pediatric oncology as an opportunity for further in-depth analysis. In patients suffering from severe organic diseases there is probably no clear-cut distinction between psychological disorder and emotional suffering. During the different phases of their disease, patients may swing to and fro in the continuous spectrum from adaptation and psychopathology. The topic is by no means marginal because it has to do with the problem of identifying the most appropriate medical and psychiatric competences needed to care for a patient’s psyche, competences that probably largely overlap. The time is now amply ripe for dealing scientifically with the problems of integration between different disciplines on this front too.
Acknowledgements
The authors would like to thank the Associazione Bianca Garavaglia for supporting the psychosocial activities and the Youth Project of the Pediatric Oncology Unit of the Istituto Nazionale Tumori of Milan. The authors would also like to thank Charles Pittman and Gaetano Filo for their advice.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
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