BC with Pre-existing Major Mental Illness - How Many?

To anyone in the US participating in or reading this thread - HAVE  HAPPY THANKSGIVING.

I know that sometimes it is really hard to find things to be thankful for, and it can often be depressing to celebrate the holidays. It can trigger depression in many people with mental illness, or cause us to relive painful family relationships. And the pressure of "celebrating" can be overwhelming.

So I will just say that I will be thinking of those for whom the holidays are more suffering than joy. Monday will be here in no time!

Oh, ((((Rose)))) so nice to both hear from you and see you on this thread. The expectations game regarding long weekends can be brutal. If I am going through a depression it can set me back. I am glad that you plan to spoil yourself rotten - you deserve it! Luckily I had a good time with my family today. Maybe I, too, am in a slightly better place.

That retail therapy is the best!:-)

pallir, I am glad your surgery is over - congratulations -a huge step for you! You should be proud.

I had to endure my first ever taste of Thanksgiving and football - yuck! My two nephews had to watch a game and in this annyingly kids-centered world they were allowed to. When it comes to American team sports and all the kitsch surrounding it - I am not at all American!

It is weird, isn't it - to have skin that behaves differently in a different part of the body. I had reconstruction with implants, so the only thing that moved was "material" from my abdomen to make the nipple. But it is confounding.

I don't think a lot of people have the Hallmark life, although many pretend they do. I had a very nice Thanksgiving this year, for which I am thankful, but I've had my share of bad ones. I think this year I just learned to adjust expectations to reality - and we had good food. :-)

I have gotten over my family's lack of support when I was struggling with bipolar hospitalizations AND breast cancer. I have gotten over it in that I don't forgive it but I accept that that's how it is. I realize, to my surprise, that they love me more than I do them. My problems were too "exotic" - they preferred to rally around my narcissistic oldest sister whose marriage was collapsing.

Funny how people who mess up of their own violtion (drugs, divorce) get more sympathy than those who don't (mentall and physical illness).

Unfortunately, they also see me as strong and less needy, which sometimes makes me angry. I don't want to have to be strong - and had they shown more support, the strength I mustered wouldn't have been necessary.

Lionesses will use all of their strength to capture and kill prey, but they try to avoid that. Use too much strength too often and you asre left scarred and weakened - NOT stronger. That bs that "what doesn't kill you makes you stronger" must have been coined by someone with a cushy life. Maybe the person had one or two bad turns and learned from it. But for many of us, what doesn't kill you now could kill you later - whether it's cancer or mental illness.

Off soap box:-)

Hope everybody else this holiday season who has been misunderstood and emotionally abandoned by loved ones is able to recover.

I have a wonderful doctor for whom I am very thankful.

Rose, you are too sweet.

I do hope others who read here and have a story to tell come forward. I can say that between my early stage cancer and the bipolar, dealing with the bipolar has been by far the hardest, but that would likely not be the case if I were stage IV.

I can totally understand how you would stay on Arimidex - the SEs can't be half as bad as, uh, liver failure, lung failure, brain mets....easy choice, in other words.

Are you getting any help from an anti-depressant, by the way? Sometimes a plain old mood stabilizer may help too. You are describing what also sound like PMS symptoms - I got those a lot on Tamoxifen and I know lots of other people on AIs have them. If you either have liver mets or concerns about liver mets you can take medications that are processed not by the liver but by the kidneys.

Love to you back!

"A"

I think a lot of the time doctors leave the decisions up to us because they, themselves, don't know what to do. Perhaps medical training is becoming too compartmentalized by specialty? I am now taking 1/2 mg/day of progynova (I think that's estrace, or estradiol) per day to prevent myself from killing myself on certain days of the month. It sounds comical, because I can also get dangerously manic if not on treatment, but it's true. My psychiatrist would not prescribe hormone therapy. My obgyn only reluctantly agreed, but wanted to wait until my suicidality returned to see if the estrogen was really low (hmmmm...I wonder how many doctors would let a patient reach heart failure or liver failure before agreeing to  treatment...this is head failure). I decided that waiting was a risk to my life, so I started taking hormones on my own. How is that fair to a patient. Haven't broken the news to my long-suffering onc, but I don't know what part of the word "suicidal" these medical practitioners don't understand.

Earth to cancer or cancer-obsessed doctors: Believe it or not, there are other things that can kill you besides cancer. And that includes the treatment- especially if you have a mental illness that requires lifelong treatment.

Probably sound like a broken record, but I believe there needs to be more awareness around this issue. Doctors need to treat the whole patient and not just the cancer.

Lioness to world: If you are reading this and it helps you, I am glad. Even better if you post and share your own thoughts. Others may read YOU and be helped.

jennyrjd - wow, you are dealing with a lot! It must have been hard to go without the estradiol on top of getting cancer.

On Tamoxifen I was so sensitive I think I would have taken umbrage, from DC, at something someone in China hinted to his neighbor. It's awful, and half of the time you wonder whether it's "just you" or whether the world has gotten that much more unpleasant all of a sudden.

May I ask what anti-depressants you are on and which third one is being considered? Are you on anything for the ADHD?

Jenny, I, too do what I can besides meds which, post Tamoxifen, have not worked as well. I exercise, work as much as I can and try to find time for hobbies, etc.. I thank God that my particular malady has some positive aspects to it.

When I hear a person say they "can make it without pills" such false bravado tells me that either they don't really have a serious mental illness, they live a chaotic, disabled life and are in huge denial, or they spend their time in and out of psych. hospitals. Meds are every bit as necessary for us as they are for someone with an infection or with cancer - lack of meds can kills us. I am conscious of the fact that I have an illness - Bipolar I --that has a mortality rate of as high as 20 percent. You don't mess with that fact. Off soap box. :-)

ADHD with depression is very, very hard to cope with on a daily basis, so you must be working very hard if you've gotten this far. Upon reading your post, the following ideas entered my mind:

• 
  
  SSRIs like Paxil are definitely libido killers. I have the same experience on my current SSRI (Celexa), although I find that the libido loss lessens with time. However, there have been times this year when you wouldn't have gotten anything out of me on the sexual end if you had put a .357 Magnum to my head!
  
  
• 
  
  Have you asked about Lexapro? It can help with anxiety as well as depression. It can also hurt libido but it may make the Klonopin and Wellbutrin unnecessary for you....I don't know.
  
  
• 
  
  Also, Strattera, an ADHD drug. can, for some people, also help with anxiety, even though it takes a few weeks to take effect. Sometimes with stimulants like Daytrana the person may experience anxiety or irritability upon withdrawal; don't know if that is the case for you but it might be worth exploring. In a few cases, people will be put on an extra, micro-dose of a stimulant to get 24 hour treatment and that may curb any anxiety. The existence of withdrawal symptoms (they are really a rebound effect more than anything) don't mean you are addicted - they are just the nasty tail of the drug leaving your system.
  
  
• 
  
  Pristiq or Effexor may also work for depression plus ADHD. Effexor or the ADHD drug Clonidine can both also work against hot flashes, believe it or not - don't know if you are experiencing any of those on your AI? Anyway, other options to explore with your doctors.
  
  
• 
  
  If you are ready to consider ECT, it is a very safe and well controlled procedure these days. A friend of mine had it for depression and said that it helped her - but each case is different, of course. It is covered by insurance, and it can work against really bad depression that doesn't respond to meds. I think it is also used, less often, against severe, treatment resistent mania.
  
  
• 
  
  Another option, if you are really having difficulty with your symptoms, is to try older classes of anti-depressants known as Tryciclics or MAOIs - they have some cardiac and dietary contraindications, but they are worth asking about, and they can also be effective against ADHD. They were the main anti-d's that existed before the advent of the SSRIs. Some of the younger pdocs have no experience with them, so I would consult an older or very experienced psychiatrist for this reason.
  
  

Edited.

Momine, studies show that what you say about lifestyle factors is true. About fear of doctors, that is likely individual; OTOH, many mental patients do have more contact with doctors than they often want to and in some cases this may mean more unpleasant experiences.

My substance of abuse was smoking - I am lucky that it wasn't drinking or drugs, I suppose (as it is with more than half of bipolars at any point in their lives). Also, partly as a result of the bipolar or perhaps as part and parcel of it, my circadian rhythms have been awful since childhood. I simply cannot sleep normally without assistance from Big Pharma; with such assistance I sleep halfway well, at best. So I had at least two major risk factors for BC.

And I am very high functioning.

For people with delusions or paranoia, it is very hard to adhere to any treatment plan. Especially for people with schizophrenia - many of the anti-psychotics produce apathy as an SE and also cognitive sloppiness which makes self-care even more difficult. That, in addition to the cognitive effect of the symptoms themselves.

Another risk factor many seriously mentally ill people, especially schizophrenics, must cope with is obesity (again, I am lucky in that respect) - the anti-psychotics can really make a person pack on pounds. I have been on them at times for short periods, and there is nothing you can do to stop the weight gain. It's awful.

Then add to that the fact that, in a manic phase or psychotic state, a person may have alienated half of the world by her/his obnoxious grandiosity, impulsiveness or eccentricity.....and by the time the cancer dx comes around others are sick of him/her and the person has to face it alone.

Fingers crossed for your brother's health, Momine!

Jenny - and this post of yours is fabulous! I agree with everything you say.

Ok, I finally purchased an article from Lancet Oncology - it is a review of the situation facing people with both severe mental illness and cancer. I am going to publish excerpts in a disroganized manner in case I incur any copyright violation.

This very technical medications part discusses possible interactions between cancer drugs and psychiatric drugs Bold is mine:

This bit discusses chemo drugs plus psych meds:

Some drugs used in oncology practice can interact with psychotropic drugs, resulting in adverse side-effects.47 Interactions can be pharmacodynamic (where pharmacological actions combine or oppose) or pharmacokinetic (where one drug affects the metabolism or excretion of another). Pharmacodynamic interactions can occur with cytotoxic chemotherapy drugs, which are often associated with myelosuppression and increase the risk of neutropenic sepsis, occasionally leading to death. Since neutropenic sepsis is a substantial risk for cancer patients receiving chemotherapy, care needs to be taken with any concomitant medication that affects bone-marrow function. Certain psychotropic drugs cause blood dyscrasias, such as clozapine (anti-psychotic),48 phenothiazines,49, 50 carbamazapine (aka Tegretol in the US - mood stabilizer),51 and, probably less often, mianserin52 and mirtazapine (Remeron in the US - anti-depressant).53 When these drugs (particularly clozapine) are used in conjunction with cytotoxics, profound agranulocytosis can result, with substantial risk of life-threatening infection, although some case reports have shown that clozapine was used safely and without agranulocytosis in patients receiving cancer chemotherapy.54, 55 Strategies are available to try and mitigate the risk of agranulocytosis in patients receiving clozapine and cytotoxic chemotherapy. Recombinant white-blood-cell growth factors can be used, or prophylactic antibiotics. Recombinant white-blood-cell growth factors are costly and in the UK their use as primary prophylaxis for neutropenia is restricted to chemotherapy regimens that are known to cause grade 3 or 4 neutropenia (neutrophils <1·0 at nadir of the chemotherapy cycle).56 Recombinant white-blood-cell factors can be used for secondary prophylaxis if a patient receiving cytotoxic chemotherapy has grade 3 or 4 neutropenia with a previous chemotherapy treatment cycle. Alternatively, the dose of the cytotoxic agents can be reduced for subsequent treatments.

Other pharmacodynamic interactions include potentiation of drug-induced prolongation of the QTc interval, which can in turn provoke ventricular tachycardia. This can occur when lapatininb, a tyrosine-kinase inhibitor (TKI), is used with other drugs that also prolong the QTc interval—ie, most, if not all, antipsychotics57 and tricyclic antidepressants58—and thus should be avoided when possible. If combined use cannot be avoided, close monitoring of QTc is clearly advisable. Many antiemetic drugs used in oncology (haloperidol and metoclopramide) are dopamine agonists. When used in combination with antipsychotics, acute movement disorders are more likely to result. Cyclizine and 5-hydroxytryptamine 3 receptor (5-HT3) antagonists might be preferred in such patients.

Many psychotropic drugs exert pharmacokinetic interactions by inhibiting the metabolism of chemotherapy, including clomipramine, duloxetine, haloperidol, paroxetine, sertraline, and fluoxetine, which can lead to an increased effect of chemotherapy and increased side-effects for tamoxifen, docetaxel, paclitaxel, and cyclophosphamide.59 Other psychotropic drugs, including carbamazepine and St John's Wort, increase the metabolism of chemotherapy drugs, resulting in lower blood concentrations and reduced efficacy of docetaxel, oestrogens, paclitaxel, progesterone, and cyclophosphamide.59

TKIs share metabolic routes (particularly via Cytochrome P450 3AF [CYP3A4]) with several psychotropics. Inhibitors of CYP3A4, such as fluoxetine and paroxetine, can increase plasma concentrations of TKIs, whereas carbamazepine and St John's Wort decrease plasma concentrations. TKIs can also inhibit CYP3A460 and increase concentrations of psychotropics such as fluoxetine, paroxetine, and carbamazepine.

This bit discusses Tamoxifen:

Tamoxifen, an anti-oestrogen used for prevention and treatment of oestrogen-receptor-positive breast cancer, is a prodrug that is metabolised to the active constituents endoxifen and 4-hydroxytamoxifen by cytochrome P450 2D6 (CYP2D6). Selective serotonin reuptake inhibitors (SSRIs) inhibit CYP2D6 to varying degrees, with paroxetine and fluoxetine being particularly strong inhibitors,61 leading to lower plasma concentrations of endoxifen. There is now growing evidence that paroxetine (Paxil in the US) use during tamoxifen treatment is associated with an increased risk of death from breast cancer,62 and this has prompted recommendations that clinicians should avoid prescribing strong CYP2D6-inhibiting SSRIs for women with breast cancer who receive tamoxifen.63 Patients already being treated with tamoxifen and paroxetine or fluoxetine (aka Prozac) should be prescribed an alternative drug with low potential to inhibit CPY2D6 (such as citalopram -aka Celexa, and also very close to Lexapro). However, abrupt discontinuation of paroxetine or fluoxetine should be avoided as immediate withdrawal of an effective treatment could lead to a recurrence of severe depression and severe withdrawal symptoms.

************

Here is the Journal reference:

Lancet Oncology, Volume 11, Issue 8, Pages 797 - 804, August 2010

Published Online: 05 July 2010

Cancer diagnosis in people with severe mental illness: practical and ethical issues

Original Text

Dr Louise M Howard MRCPsych a , Elizabeth A Barley PhD a, Elizabeth Davies FFPH b, Anne Rigg MRCP d, Heidi Lempp PhD e, Diana Rose PhD a, Prof David Taylor PhD c, Prof Graham Thornicroft PhD a

....and this bit I will intersperse with my peanut gallery comments if I may - it talks about the frequency of cancer with comorbid mental illness and advocacy.

There are several publications on the implications of mental illness on cancer screening and treatment,76 including first-person narratives.77 Issues such as facilitators and barriers to screening and cancer treatment for those with a severe mental illness have been discussed; however, very few studies were from the perspective of a mental health-service user. People living with cancer, and patients living with severe mental illness have been active in advocacy, self-help, and in shaping the research agenda;78 however, activities of the two groups rarely overlap (that's why I started this thread). This lack of collective effort could be partly because the population of individuals with both conditions is small (now I REALLY feel lucky!). There might also be issues of stigma. Sontag79 argued that cancer was the unspeakable condition at the time she was writing. We suggest that severe forms of mental illness have taken over the role that Sontag identified for cancer as the ultimate personal and social threat. The current antistigma campaign in England, Time to Change, features a poster of a woman stating that people found her cancer much easier to deal with than her depression. The paucity of published work on living with both cancer and mental illness might be the result of a double stigma, but one where mental health is the dominant element. Worse, the stigma of mental illness can have deleterious effects on identification and treatment of malignant disease for those who also have a known psychiatric diagnosis.

*****

Here again, article ref:

Lancet Oncology, Volume 11, Issue 8, Pages 797 - 804, August 2010

Published Online: 05 July 2010

Cancer diagnosis in people with severe mental illness: practical and ethical issues