Psychotropic medication use in cancer patients- a Chinese perspective.

Despite recent improvements in the treatment and survival of many cancers, cancer remains a life-threatening diagnosis. This often brings significant psychological distress and anxiety, which may last for extended periods of time, leading to a clinical diagnosis of a mental illness. Patients often experience fears about death, suffering and change in social roles. Oncological treatments such as chemotherapy may also impact upon patients’ mental health. Indeed, cancer patients have higher rates of major depression, anxiety, sleep disturbances, and adjustment disorders [1]. Additionally, for those with pre-existing disorders, many may experience an exacerbation in symptoms after a cancer diagnosis. These disorders have a real impact for patients, not only affecting quality of life, but also are associated with treatment delays, reduced adherence to treatment, prolonged hospitalizations and decreased survival [2,3]. Yet many go undiagnosed and undertreated.

Published in the Lancet Regional Health – Western Pacific Bai and colleagues present the first study of the prevalence of psychotropic use in cancer patients in China [4]. In this cross-sectional study, using a national representative sample of basic medical insurance beneficiaries, the authors identified 260 364 adults with cancer (2015–2017). 18•5% of the identified cancer patients were prescribed at least one psychotropic medication, with hypnotics and sedatives being the most common (14•2%) followed by anxiolytics (6•1%), antipsychotic (1•4%) and antidepressants (0•95%). The authors identified a higher prevalence of psychotropic medication use among females, those 45 or older and among those with solid organ cancer, particularly cancers of the urinary tract and female genital organs.

One notable finding from the study was the disparity in treatment access based on region and insurance coverage. The authors found patients from eastern regions of China were more likely to use psychotropic medications than those in other areas, likely reflecting greater levels of economic development and healthcare resources. Similarly, those covered by the Urban Employee Basic Medical Insurance (UEBMI) had a greater prevalence of use compared to the Urban Rural Resident Basic Medical Insurance (URBMI). URBMI covers rural residents, the self-employed and the urban non-employed (including for example children and the elderly) while UEBMI provides mandatory cover for employees in urban areas. These observations are likely influenced by lower socioeconomic levels, lower education attainment, greater out of pocket costs and reduced access to tertiary care among URBMI members [5]. However, data on factors such as socioeconomic status and education was not available, a notable limitation. Substantial variations in healthcare utilization have been reported within China, including for patients with psychiatric disorders [5,6]. In recent years, as part of the Healthy China 2030 vision, China has strived to expand healthcare coverage, and narrow gaps in health insurance, launching the medical security scheme for URBMI in 2016, narrowing urban-rural inequities in financial subsidies, contribution levels and treatment [7]. Yet these results highlight that further work remains in bridging gaps in the utilization of healthcare in the mental health setting.

The prevalence of psychiatric disorders among Chinese patients with cancer has been reported to be considerably high, with approximately 60% experiencing depression [8,9]. Therefore the low rates of psychotropic medication use observed in this study raises important public health concerns surrounding the apparent under-treatment of psychiatric disorders in this patient group. The authors propose a number of plausible explanations including the lack of psychiatric expertise and care within general hospitals and in the oncology setting, leading to under diagnosis and treatment. Furthermore, social stigma may influence somatization and discourage health seeking behavior [10]. In 2003, a World health study reported that only 1% of Chinese patients with symptoms for depression received treatment [11], while only 6.9% of cancer patients with depressive disorders were treated by oncologists [10]. Importantly however, the prevalence of psychiatric disorders was not reported for this specific study population, therefore it remains unknown if this truly reflects underuse.

A number of other limitations should also be considered, and caution exercised, when interpreting results of this study. This study was cross-sectional and as such temporality could not be determined. It remains unclear if psychotropic medications were prescribed pre- or post- cancer diagnosis, or at what time point medications were prescribed following diagnosis, including if pre- or post- cancer treatment or in the palliative care setting. Questions too remain, if utilization may differ by individual cancer types, cancer stage or by specific cancer treatment. The indication of psychotropic treatment is also unclear. This has particular importance in this setting as a number of psychotropic medications are in fact indicated as antiemetic's to control nausea and vomiting associated with cancer treatment. Finally, the study failed to capture all psychotropic medications, for example with no information on anti-epileptics and for those patients not covered by basic medical insurance.

Nevertheless, this study raises important public health questions surrounding the provision, quality and equity of psychiatric care for cancer patients in China. Oncologists should be aware of, and adequately monitor patients for depression, anxiety and other psychiatric conditions after cancer diagnosis, considering not only pharmacological treatments, but also psychosocial interventions. Further research utilizing robust longitudinal data is urgently warranted to fully elucidate the utilization of psychotropic medications among cancer patients in China.

Declaration of Competing Interests

The author has nothing to declare.