Roughly half of the Japanese population experiences cancer, a distressful experience which can be accompanied by depression. In this review, we compare findings from studies on the pathophysiology of depression in cancer patients with findings from studies of depressed individuals without cancer. Several neuroimaging studies of depressed cancer patients found that parameters such as hippocampal volume and subgenual anterior cingulate neural activity were similar to those in depressed individuals without cancer. In contrast, levels of biological markers derived from blood samples such as interleukin-6, brain-derived neurotrophic factor, and omega-3 fatty acids in depressed cancer patients differed from those in physically healthy depressed individuals. These differences may suggest that the pathophysiology of depression in cancer patients also differs from that of physically healthy depressed individuals. Given the variety in cancer type, clinical stage, and treatment, the pathophysiology for depression among cancer patients may also vary widely by patient. Further studies are needed to elucidate the pathophysiology of depression in cancer patients.

This review focused on our neuroimaging studies about posttraumatic stress disorder (PTSD) and intrusive symptoms in cancer patients. At the beginning, we reported smaller left hippocampi and amygdalae in breast cancer survivors with intrusive symptoms at 3 years or more after surgery. In order to approach the causality, we investigated the effect of hippocampal volume on enhanced emotional memory in healthy women. Left hippocampal volume showed a significant inverse correlation with enhanced emotional memory. These findings support that smaller left hippocampus in cancer survivors with intrusive symptoms represent a pre-existing vulnerability factor rather than the neurotoxic effect of persistent intrusive symptoms. As the frequency of large cavum septi pellucidi was not associated with intrusive symptoms, the possibility of neurodevelopmental anomaly was not accepted. Cancer-related PTSD was not associated with either hippocampal or amygdala volume at 1 year after surgery, but we found an inverse association between intrusive symptoms and hippocampal volume. Furthermore, the gray matter volume of the right orbitofrontal cortex, estimated by voxel-based morphometry, was significantly smaller in cancer survivors with PTSD than in those without PTSD or healthy subjects. Although neuroimaging data don’t contribute clinical assessment or psychological care, understanding of hippocampal involvement in intrusive symptoms may be likely to provide initiating new intervention strategy.

In clinical oncology settings, both patients and physicians suffer from intense emotional anguish when discussing bad news. Patients' preferred communication consists of four components: setting up a supportive environment for interview, considering how to deliver bad news, discussing additional information, and providing reassurance and addressing patients’ emotions with empathic responses. The four components are associated with patients' psychosocial characteristics and cultural backgrounds. Based on the patients' preferences, a new communication skills training (CST) program for physicians have been developed in Japan. It is shown that communication skills that comply with patient preferences can be taught to physicians and their utilization decreases patient distress and improves physician performance and confidence in communicating with patients, using a randomized design. It is expected that all physicians will be provided an opportunity to learn communication skills and these efforts will further communication between patients with cancer and their physicians.

To clarify the pathophysiology of delirium, various psychophysiological studies on delirium were reviewed. In brain structure studies by computed tomography (CT) and magnetic resonance imaging (MRI), cerebrocortical atrophy, areas of white matter hyperintensity, and lesions of the basal nucleus were found in delirious patients. In terms of brain function, single photon emission computed tomography (SPECT) showed that brain blood flow was decreased in the prefrontal lobe and increased in the striatum and infratemporal lobe, or decreased in the thalamus and basal nucleus of delirious patients. With electroencephalography (EEG), slowing in the posterior dominant rhythm and generalized theta or delta slow-wave activity were recognized in delirious patients. Inspection combining EEG and ocular movements in hyperactive delirium patients showed characteristic low amplitude and slowing in background EEG activity and RS-type eye movements comprising rapid movements juxtaposed over slow movements. Hypoactive delirium is frequently recognized in cancer patients, in addition to hyperactive delirium. The pathophysiology of whole delirium may thus be elucidated if delirium studies for cancer patients are performed using psychophysiological methods.

Although benzodiazepines (BZs) are widely used, their adverse effects - such as dependency - have made clinicians concerned about proper BZ usage. The Tokyo Women's Medical University Hospital began performing educational activities, such as distribution of a short leaflet and running an educational workshop, on proper BZ usage. These activities were operated by the departments of psychiatry and pharmacy and a medical safety committee. The leaflet included the name, efficacy, adverse effects, and methods of discontinuing BZs, as well as providing information on coping techniques other than medication and introducing the psychiatry department. As a result of these activities, the number of patients receiving BZ prescriptions was reduced by 18%. Moreover, the BZ prescription rate in all medicated patients was reduced by 4%. No problems were reported in the survey of pharmacists. The findings suggest that our brief activity reduced BZ prescription without major problems.

In the Asakura Medical Association Hospital (our hospital), one psychiatrist performs consultation-liaison services for only half a day each week, as a part-time service. In our hospital, all information regarding patients with psychiatric symptoms and those requiring mental follow-up is gathered by clinical psychologists, and these clinical psychologists intervene for all such patients and refer to a psychiatrist only when necessary. Consequently, about 70% of the referred patients undergo intervention with clinical psychologists alone. While the psychiatrist is on duty for half a day, in many cases, consultation-liaison services may be sufficient with the clinical psychologists alone. In our hospital, many cases improved with clinical psychologist intervention and did not require pharmacotherapy for adjustment disorders. The activities of the clinical psychologists in our hospital suggest that clinical psychologists are essential in a general hospital without a full-time psychiatrist in charge, and suggest that it could be recommended to expand their activity in hospitals with a part-time psychiatrist.

Psychopathology of cardiovascular surgeons is being paid attention to non-technical skills of surgeon are being recognized as essential parts of safe performance of cardiovascular operations. Questionnaires were sent to board-certified cardiovascular surgeons in Gunma Prefecture, Japan. Questionnaires consisted of Quick Inventory of Depression Symptomatology and an original inventory focusing on perioperative surgeons stress coping developed by us. Twelve surgeons (46.2%) responded. Quick Inventory of Depression Symptomatology showed nobody who needed psychiatric intervention. An original inventory showed hypomania in 25% surgeons, which was thought to be advantageous in performing safe and swift operations, and the inventory showed immature defense mechanism in another 25%. Board-certified cardiovascular surgeons in Gunma Prefecture were free from major depression. Some were in hypomania state, which favored operation. The majority was using a mature defense mechanism and properly acquired cognitive ability to cope with intraoperative stress.