Volume 3 Issue 12 December, 2013
Consultation Liaison Psychiatry Focus: ‘Hematology’
Hematology is a branch of medicine which deals with blood and blood related disorders. Hematological problems may, vary from sudden, severe and life threatening to long term chronically progressive and may lead to lifelong misery, discomfort and anxiety to the patients. Diagnosis of such severe problems can have sudden, severe and devastating effect not only on the patient, but also their family members.
Psychiatric problems are frequently encountered in hematology patients. The severity of symptoms may vary from mild
anxiety to severe depression. These symptoms may be part of the disease per se, or as a consequence of patient’s apprehension about the diagnosis, difficulty in understanding the treatment modalities or as a consequence of financial implications of the disease or treatment.
Hematological disorders, for example Megaloblastic anemia of vitamin B12 deficiency is associated with problems in
cognition, mood, psychosis, and less commonly, anxiety. Folate deficiency primarily is associated with problems in mood. Patients who have sickle cell disease, a disease of chronic pain, experience difficulties with depression, anxiety, stigma, and are at risk for substance abuse and dependence. Iron deficiency anemia is associated irritability, depression. Disorders like haemophilia are associated with significant psychiatric manifestations. In a study, Sixty seven percent of them were anxious, 60% were depressed, 60% showed aggressive characteristics, 72% had obsessive-compulsive traits and 71% had psychiatric features while 52% showed somatization characteristics. Findings also revealed that occurrence of similar disorders among control group were three to four times lower than hemophiliac patients. Other major haematological disorders are leukemia, lymphoma and myeloma. In a study, during a six-month period, the total group of hospital inpatients suffering from leukemia, Hodgkin’s disease or non-Hodgkin’s lymphoma, were assessed, using a semi-structured interview. A prevalence of 30% of adjustment disorders (depression and/or
anxiety) and 2% of organic mental syndromes was found employing the DSM-III-R diagnostic system. In a prospective inpatient study conducted from July 1994 to August 1997, 220 patients aged 16 to 65 years received Stem Cell Transplantation for hematologic cancer at a single institution, the study results reveal, overall psychiatric disorder prevalence was 44.1%; an adjustment disorder was diagnosed in 22.7% of patients, a mood disorder in 14.1%, an anxiety disorder in 8.2%, and delirium in 7.3%. Hematological manifestations can also occur in psychiatric patients. Anemia is the most common hematologic manifestation of psychiatric disorder, whether mania, depression, or other psychotic, or neurotic disorder.
In addition, almost all classes of psychotropic agents have been reported to cause blood dyscrasias. Mechanisms include direct toxic effects upon the bone marrow, the formation of antibodies against haematopoietic precursors or involve peripheral destruction of cells. Agranulocytosis is probably the most important drug-related blood dyscrasia. The mortality from drug-induced agranulocytosis is 5-10% in Western countries. The manifestations of agranulocytosis are secondary to infection. Aggressive treatment with intravenous broad-spectrum antimicrobials and bone marrow stimulants may be required. Of drugs encountered in psychiatry, antipsychotics including clozapine (risk of agranulocytosis approximately 0.8%, predominantly in the first year of treatment) and phenothiazines (chlorpromazine agranulocytosis risk approximately 0.13%), and antiepileptics (notably carbamazepine, neutropenia risk approximately 0.5%) are the most common causes of drug-related neutropenia/agranulocytosis. Drugs known to cause neutropenia should not be used concomitantly with other drugs known to cause this problem. High temperature and other indicators of possible infection should be looked for routinely during treatment. Clozapine is well known as a drug that can cause blood dyscrasias, but olanzapine and other atypicals may also cause similar problems. In addition to genetic
factors, there are likely to be dose-related and immunological components to these phenomena. Important lessons have been learnt from the haematological monitoring that is necessary with clozapine and the monitoring has been very successful in preventing deaths related to clozapine-induced agranulocytosis. Continuing research into the mechanisms of drug-induced neutropenia and agranulocytosis may serve to further enhance the safe use not only of clozapine, but also of other agents.
The summary of various studies suggest psychiatric manifestations are common, more frequent than expected in
haematological disorders. In psychiatric patients, haematological problems are also common, either as a part of the disease or as a result of therapy.
Dr. Arun V, MD, DM, Consultant Hematologist & Hemato-oncologist J S S hospital, Mysore.
