1 / 40

Psycho-Oncology and Palliative Care

Psycho-Oncology and Palliative Care. APM Resident Education Curriculum. Bradford D.  Bobrin , MD Medical Director, ACT Program Division Chief, Psychiatry Consult Service The Reading Hospital and Medical Center Reading, PA. Reviewed Summer 2011 Kristen Brooks, MD Assistant Professor UCSF.

kioshi
Download Presentation

Psycho-Oncology and Palliative Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Psycho-Oncology and Palliative Care APM Resident Education Curriculum Bradford D. Bobrin, MD Medical Director, ACT Program Division Chief, Psychiatry Consult Service The Reading Hospital and Medical Center Reading, PA Reviewed Summer 2011 Kristen Brooks, MD Assistant Professor UCSF Reviewed Fall 2013 Ryan Kimmel, MD Assistant Professor Univ. of Washington

  2. Palliative Care and Psychosomatics James L Levenson, M.D., 2005. • Hospice began in France in 1840s • Involves all stages of life-threatening illness • Includes psychological, social, spiritual, and cultural issues • Palliative care …. • Affirms life and regards dying as normal • Neither hastens nor postpones death • Provides relief from pain and other symptoms • Integrates the psychological and spiritual • Offers support system to help patient live life actively • Helps family cope • Utilizes a multidisciplinary approach

  3. Psychiatry and Palliative Care___________________________________Working Together Towards a Common Goal JLSpeiss, 2002 • Palliative care’s goal is to relieve symptoms and suffering and improve the patient's quality of life • Palliative informs psychiatry • Assessment and treatment of pain • Bereavement • Anticipatory loss • Psychiatry informs palliative care • Assessment of psychiatric illness and mental status changes • Evaluation of capacity • Psychiatric treatment • Insight into personality structure and communication issues • Conflict resolution

  4. Common Psychiatric Issues In the Palliative Care Population James L Levenson, M.D., 2005, Wyszynski, 2005 • Anxiety • Bereavement • Depression • Delirium

  5. Anxiety in Palliative Care James L Levenson, M.D., 2005, Wyszynski, 2005, LW Roberts 2004 Ranges from 15-28% and is most often comorbid with depression Prevalence increases with advanced disease and decline in physical status Includes fears of clinical course, treatment outcomes, death, social stigma, and/or physical symptoms (such as dyspnea or pain)

  6. Causes of Anxiety in Palliative Care James L Levenson, M.D., 2005,Wyszynski 2005 • Anxiety symptoms can be caused by various medical complications • Hypoxia, • Pain • Drug side effects (akathisia) • Substance withdrawal • Pulmonary embolism (PE) • Electrolyte imbalance, • Dehydration • Fear of isolation and separation of death

  7. Anxiety Treatment in Palliative Care James L Levenson, M.D., 2005 • Benzodiazepines • Multiple routes of administration (PO, IV, IM or PR) • Neuroleptics may be safest when there is a concern of respiratory depression • Multiple routes of administration(PO, IV, or IM) • Supportive psychotherapy, guided imagery, and hypnosis • SSRIs of limited value in patient when life expectancy is only a few days to weeks

  8. Bereavement James L Levenson, M.D., 2005, LW Roberts 2004 • Anticipatory Grief • Draws family closer • Acute Grief • Numbness  Distress  Disorganization  Reorganization Recovery and progression • Complicated Grief • Complicated by depression, anxiety, and substance use • Chronic Grief • Social withdrawal and isolation along with a fantasy of reunion may lead to suicidal ideation • Traumatic Grief • Often complicated by the inability to communicate “good-bye”

  9. Depression in Palliative Care James L Levenson, M.D., 2005 • Prevalence 9-18% • Loss of meaning and lower spiritual well-being lead to higher levels of depressive symptoms • Pain and functional status also factors in increased rates of depression • Underlying medical conditions may also contribute to depressive symptoms • CNS lesions, metabolic-endocrine complications and paraneoplastic syndromes • Treatment of medical conditions may also induce depressive symptoms • Whole brain radiation, corticosteroids, vincristine, vinblastine, asparaginase, intrathecal methotrexate, interferon, amphotericin

  10. Assessing Depression in the Terminally Ill James L Levenson, M.D., 2005, Takechi 2003 Diagnosis often relies more on psychological or cognitive symptoms than physical complaints Hopelessness that is pervasive with despair and despondency likely indicates depression Suicidal ideation, even mild or passive, more likely to indicate significant depression

  11. Treatment of Depression in Terminally Ill James L Levenson, M.D., 2005, Wyszynski 2005 • Prognosis and time frame affect medication choice • SSRIs for person with several months • Low dose stimulants for those with several weeks • Sedatives or narcotic infusions for those with hours to days • Start antidepressants at half the usual starting dose • Methylphenidate 2.5-5 in morning and noon • Maximum dose is usually less than 30mg/d. • Psychotherapy • Mixture of supportive, CBT and medications. • Newer modalities such as meaning-centered psychotherapy and dignity-conserving care have also been found to be helpful

  12. Suicide and Suicidal Ideation in Palliative Care James L Levenson, M.D., 2005 • Risk Factors • All regular risk factors for suicidality are important to consider • Age, race, history of suicide attempts, psychiatric illness, means, etc • Advanced stages of the disease • Hopelessness • Uncontrolled pain • Confusional states (delirium) • Loss of control and sense of helplessness • Fatigue of all forms • Physical • Financial • Social support • Suicidal ideation needs to be addressed, but psychiatric hospitalization may not be indicated in some cases

  13. Desire for Hastened Death James L Levenson, M.D., 2005 • Risks • Depression plays a role in requests for hastened death • Patients with depression were noted to have a 4x higher likelihood of desire for hastened death • These patients have higher levels of pain and less support • Psychological distress, social factors, spiritual distress and feeling like one is a burden contribute • Management of physical and psychological distress is likely the best treatment

  14. Delirium in Palliative Care JL Levinson 2005 • Prevalence of 25-85% especially in the last weeks of life • Rates of cognitive impairment rise just prior to death up to 62% in cancer patients • Terminal delirium has a 88% prevalence before death • In one study 54% recalled their delirium after recovery • The biggest risk factor for distress during episodes of delirium are the presence of delusions • Delirium may not be reversible in the last 24-48h of life (terminal delirium)

  15. Delirium (continued) JL Levinson 2005 • Variable rates of resolution • One study showed a 68% improvement rate despite 31% mortality in 30 days • Another study a cause was found in 43% and 1/3 improved • Another study showed that 50% of episodes of delirium in the last week of life were reversible • Potential causes of delirium in the terminally ill often include… • Dehydration • Psychoactive or opioid medications • Hypoxia • Other metabolic derangements

  16. Overall Psychological Treatment Goals James L Levenson, M.D., 2005, JL Speiss, 2002, LW Roberts 2004 • Help patients maintain control of their lives • Assist in developing healthy coping strategies • Help control • Anger • Denial • Panic • Despair • Fears of rejection and abandonment • Help establish self-respect by assisting with resolution of guilt, shame and self-blame • Help with communication and the maintenance of support systems

  17. Overall Psychological Treatment Goals James L Levenson, M.D., 2005 Help maintain interpersonal relationships Help develop strategies to deal with real and anticipated crises Help identify and address “unfinished business” Work with patient to explore meaning of death Help manage depression and anxiety or other psychiatric symptoms that may result from psychological issues or effects of treatment

  18. Dignity Conserving Treatment Chochinov, H, 2007 • Dignity therapy • Treatment is based on strong association with undermined dignity and: • Depression • Anxiety • Desire for death • Hopelessness • Feeling of being a burden on others • Overall poorer quality of life • Some studies even suggest that psychosocial and existential issues may be of greater concern than pain and physical symptoms

  19. Dignity Conserving Treatment Chochinov, H, 2007 • Dignity therapy • Primary themes of dignity: • Generativity • Life has stood for something • Continuity of self • Maintain one’s essence is intact • Role preservation • Being able to maintain a sense of identification with roles previously held • Maintenance of pride • Ability to sustain positive self-regard

  20. Dignity Conserving Treatment Chochinov, H, 2007 • Dignity therapy • Primary themes of dignity (cont.): • Hopefulness • Ability to find and maintain a sense of meaning or purpose • Aftermath concerns • Worries or fears concerning the burden death will impose on others • Care tenor • Attitude and manner with which others interact with the patient either promotes or diminishes dignity • Many of these are also essential to a patient maintaining a sense of control and integrity in any setting

  21. Dignity Conserving Treatment Chochinov, H, 2007; Bennington-Davis, M, 2005 • Dignity therapy (provider): • Treatment of the provider consists of an A, B, C, D approach to teaching interactions • The hope is to allow care givers, institutions, and families a way to better interact with patients to achieve the desired effect • Our thoughts about an interaction with a patient shape the interaction itself • Engagement Model

  22. Dignity Conserving Treatment Chochinov, H, 2007 • Dignity therapy (provider): • A—Attitudes • How would I feel in this situation? • What leads me to think that way? • Am I aware of how I might be affecting the patient?

  23. Dignity Conserving Treatment Chochinov, H, 2007 • Dignity therapy (provider): • B—Behaviors • Treat contact with patients as you would any important intervention • Always ask permission to do something • Act in a professional and respectful way at all times • Examples • Knock on the patient’s door • Use the patient’s proper name and title unless given permission to do otherwise

  24. Dignity Conserving Treatment Chochinov, H, 2007 • Dignity therapy (provider): • C—Compassion • Very difficult to “train” • Medical Humanities in school • Considering the personal stories • D—Dialogue • “What should I now about you as a person to help me take the best care of you that I can?” • “Who else (or what) will be affected by what’s happening?”

  25. Nausea and Vomiting James L Levenson, M.D., 2005 • Common source of distress • May become a conditioned response and evolve into an anticipatory nausea • Rapid onset benzodiazepines are helpful in anticipatory or conditioned nausea • Behavioral therapy is also effective • Antiemetics are the usual treatment for “routine” nausea and vomiting • Beware of akathisia with the dopamine antagonist antiemetics

  26. Psychiatry and Cancer(Psycho-Oncology)

  27. Psychiatric Aspects of Cancer Treatment James L Levenson, M.D., 2005, SLB Mueller 2005 • Chemotherapy • Drug interactions • Procarbazine is a weak MAOI • Paroxetine , fluoxetine, and bupropion are strong 2D6 inhibitors and may decrease the efficacy of tamoxifen due to enzyme inhibition , thus reducing levels of tamoxifen’s active metabolite (endoxifen). • Venlafaxine likely the safest choice (see Desmarais, Maturitas, 67 (2010) 296-308). • Radiation • Increased fatigue, N/V, and anxiety • Bone Marrow Transplant • Depression and anxiety, N/V, fatigue, adjustment d/o, dependence (dependent needs are associated with poorer survival), neurocognitive deficits due to CNS toxicity

  28. Psychiatric Issues Following Cancer Treatment JR Sattin 2009, SLB Muller 2005, Takechi 2003 • 3-55% get depressed following breast cancer treatment • Cognitive problems include disturbed consciousness, cognitive problems, executive problems, aphasia, apraxia and agnosia • In a study of 8, 921 women with breast cancer • Women who got surgery and chemo had increased rates of adjustment d/o and fatigue • Mood disorders were similar in chemo and non-chemo groups • No issues with cognitive disorder

  29. Depression and Cancer CP van Wilgen 2006, JL Levinson 2005, KM Brintzenhofe 2009 • May lead to poor treatment adherence and possibly decreased survival • Increased rates of depression in cancer patients over the general population • 25% rate overall • Differs for different cancers • Orophargngeal 22-57% • Pancreatic 33-50% • Breast 1.5-46% • Lung 11-44% • Depression appears to be less common in colon cancer, gynecological malignancies and lymphoma

  30. Depression and Cancer Progression and Mortality JR Satin 2009 • Depression found to have a small but significant predictor of mortality • 26% greater mortality with depressive symptoms • 39% greater mortality with MDD • Depression may be independent risk factor for mortality • Depression not associated with cancer progression

  31. Somatic Symptoms and Depression in Cancer Takechi 2003, Van Wilgen 2006 Mueller 2005 • Somatic symptoms of depression in cancer patients • Appetite changes and decreased ability to think coincided with anhedonia • Sleep disturbance and fatigue not significantly associated with non-somatic symptoms • Appetite changes associated with increased severity of depression

  32. Mixed Depression/Anxiety in Cancer Patients KM Brintzenhofe-Szoc 2009 • 8, 265 patients with cancer • Mixed symptoms in 12.4% • Depression in 18.3% • Anxiety in 24% • 70% had neither • Mixed symptoms in stomach, pancreatic, head and neck and lung cancers • Lower rates in those with breast cancers • Mixed symptoms in 2/3 of depressed cancer patients

  33. Suicidal Ideation and Cancer James L Levenson, M.D., 2005 • Passive SI common • Risk factors • Regular risk factors for suicide in the general population • Advanced disease and poor prognosis • Delirium • Pain • Physical, social, and/or financial exhaustion • Need for control

  34. Anxiety and Cancer MH Antoni 2006, JL Levenson 2005 • Common at start of treatment, recurrence, progression or at follow-up visits • 18% overall rate of anxiety disorders • 3-10% PTSD in patient’s with breast cancer • Multiple potential medical etiologies of anxiety symptoms • Nausea • Akathisia • PE • Pain

  35. Mania in Cancer JL Levinson, 2005 Recurrence of pre-existing illness Steroids Infection Diencephalic tumors

  36. Demoralization vs. Depression Slide adapted from Mitch Levy, Univ of Washington Demoralization • Characterized by “various degrees of helplessness, confusion and subjective incompetence” to adversity. • Shorter duration than depression• Reactive to family and supports • Specific to stressors • “How would you be coping if this went away?”

  37. Treatment Targets for Brief Psychotherapy for Demoralization: Resilience• Coherence• Communion • Hope• Agency• Purpose• Courage• Gratitude Griffith and Gaby,, Psychosomatics, 2005 Existential Postures of Vulnerability and Resilience Vulnerability • Confusion• Isolation• Despair • Helplessness• Meaninglessness • Cowardice• Resentment

  38. Promoting Resilience Slide adapted from Mitch Levy, Univ of Washington • Assess for prior strengths and life challenges. –What have you overcome previously like this? –What has helped in the past? –How do you cope with adversity? • Engage the family and members of the treatment team.

  39. References 1) M.H. Antoni, et., al., Reduction of Cancer Specific Thought Intrusions and Anxiety Symptoms with a Stress Management Intervention Among Women Undergoing Treatment for Breast Cancer, Am J Psychiatry, 2006, 163(10): 1791-97. 2) KM Brintzenhofe-Szoc, et.al., Mixed Anxiety/Depression Symptoms in a Large Cancer Cohort: Prevalence by Cancer Type, Psychosomatics, 2009, 50(4):383-391 3) JL Griffith and L Gaby, Brief Psychotherapy at the Bedside: Countering Demoralization From Medical Illness, Psychosomatics, 2005, 46:109-116 4) James L Levenson, M.D., The APA Publishing Textbook of Psychosomatic Medicine, APA Press, Washington DC, 2005 5) S. L.B Muller, et., al., Psychiatric Sequele Following Breast Cancer Chemotherapy: A Pilot Study Using Claims Data, Psychosomatics, 2005, 46(6):517-522. 6) LW Roberts and AR Dyer, Caring for People at the End of Life in, Concise Guide to Ethics in Mental Health Care, APA Publishing, Washington DC, 2004: 185-95 7) J.R. Satin et., al., Depression as a Predictor of Disease Progression and Mortality in Cancer Patients, Cancer 2009. 8) JL Spiess, Palliative Care: Something Else We Can Do For Our Patients, Psychiatric Services, 2002, 53(12):1525-29

  40. References 8) N. Straker, Psychodynamic Psychotherapy for Cancer Patients, Journal of Psychotherapy Practice and Research, 1998, 71-9. 9) Takechi, et., Al.,: Somatic Symptoms for Diagnosing Major Depressive Disorder in Cancer Patients, Psychosomatics, 2003, 44(3): 244-48 10) CP van Wilgen, et., al., Measuring Somatic Symptoms with the CES-D to Assess Depression in Cancer Patients After Treatment: Comparison Among Patients with Oral/Oropharyngeal, Gynecological, Colorectal and Breast Cancer, Psychosomatics, 2006, 47(6): 465-470. 11) Antoinette Wyszynski and Bernard Wyszynski, Manual of Psychiatric Care for the Medically Ill, APA Press, Washington, DC, 2005.

More Related