Psychiatric Aspects of Care Flashcards
Prevalence and risk factors for anxiety/depression in PC
- 15-20% incidence of patients with advanced disease
- Sub-diagnostic symptoms even more common
Risk factors
- Less spiritual well-being
- Lower self-esteem
- Previous hx depression (and family history)
- Perceived lack of social support
- Higher disease burden
- Younger age
- Declining functional status
- Pain and poor symptom control
- Comorbid neurologic disorders
- Certain chemotherapy agents (vinorelbine, paclitaxel, docetaxel, vincristine), hormonal agents, and antihypertensives (propranolol)
- Specific cancers (pancreatic, lymphoma, lung ca) likely due to increased pro-inflammatory cytokines
- Gender is not a significant factor (in the general population, women are at higher risk, but this is not the case for the advanced disease population)
Why is younger age associated with increased risk of depression
- Greater sense of loss
- Less prior experience of coping with illness and adversity
- Greater capacity among older people to find meaning and experience secure attachment relationship
Clinical significance of untreated anxiety
- More physical distress (fatigue, pain, dyspnea, anorexia
- Lower overall sense of well-being
- Less confidence in the ability of their medical team to adequately control their symptoms
- Greater difficulty in asking questions about their medical situation
- ## Greater difficulty understanding information presented to them
Clinical significance of untreated depression
- Limits participation in EOL care
- Increased risk of impaired QOL
- Increased risk of suicide and desire for hastened death
- Amplifies pain
- Associated with poorer self-care
- Twofold increase in utilization of healthcare services
- Diminished survival in advanced cancer
- Reduced treatment adherence
- Poorer tolerance of side effects
- Ambivalent-decision making
- Pessmism about outcome and benefit of treatment
Is sadness a normal part of the dying process?
- Normal human grief reaction
- May also be part of a search for meaning
- Important not to pathologize normal sadness but low mood, anhedonia, hopelessness, or suicidal ideation that is persistent should trigger consideration of an MDE
Desire for hastened death
- Common in patients with advanced disease
- 45% have an occasional desire for hastened death, 9% had a serious and persistent desire to die and had higher rates of depression
- May be related to acceptance of death rather than hopelessness
Approach:
- Allow thoughts to be explored
- Acknowledge and validate distress, concerns, and fears
- Consider working with interprofessional team
Suicidality in Palliative patients - risk factors
- Incidence of suicide in cancer patients is twice as high as in general population
Risk factors:
- Male gender
- Caucasion
- Older age at dx
- Certain types of cancer (lung, stomach, head and neck)
- Concern re: lack of autonomy
- Dependence on others
Risk assessment for suicide
Suicide Assessment Five Step Evaluation and Triage (SAFE-T)
Modifiable factors that may contribute to depression
Biological
- Symptom review
- Anemia
- Malnutrition
- Hypothyroidism
- Med use/withdrawal (Steroids, Cytokines like IL-2, GNRH agonists)
- Substance use/withdrawal (smoking, alcohol, etc.)
Psychosocial
- Psych factors
- Existential concerns
- Role changes
- Social supports
- Unresolved conflicts
- Caregiver burnout
- Practical/day to day support
- Previous trauma
- Previous losses
- Attachment security
- Communication with treatment team
- Life stage
- Fear of dependency
Pharmacological treatments for depression in palliative care
SSRIs or SNRIS (may take up to 8 weeks for partial or full benefit)
- Citalopram, sertraline, and escitalopram (SSRIs) have lowest level of drug-drug interactions
- Common short term side effects: Headache, sedation or activation, hyponatremia in the elderly, GI upset at the time of initiation, discontinuation syndrome
- Suicidal ideation can increase, especially in adolescents or young adults
Bupropion
- Helpful with fatigue, hypersomnia, psychomotor retardation
Mirtazipine
- Sedation, appetite stimulation
Stimulants
- Methylphenidate
- Have been used, but efficacy as an antidepressant not confirmed in RCT
- May improve fatigue, but worsen anxiety, anorexia, and sleep difficulties
Psychosocial treatments for depression in palliative care
- Limited evidence for psychological intervention, but relaxation strategies, CBT, and supportive tx may be helpful
- Some patients may benefit from referral to psychology, particularly for highly motivated patients
GAD - diagnostic criteria
WATCHER
- Worry
- Anxiety
- Time for at least 6 months
- Controlling the worry difficult
- Handicapping
- Exclude another mental disorder
- Rule out worry, not due to physiological effects of a substance or another medical condition
*May identify as ‘worriers’ but not meet full criteria for GAD until faced with the stressors of medical illness
Acute stress disorder - diagnostic criteria
TRAUMA
- Traumatic event: witnessed or experienced or occurred to dearest or exposure repeatedly to its aversive details
- Re-experience one of following intrusion symptoms: memories, nightmares, flashbacks, psychological distress or physiological reaction to cues symbolising the traumatic event
- Avoidance of memories, thoughts, feelings of the traumatic event or its reminders
- Alterations in cognitions and mood negatively: forgetting, mislabelling, blaming, no positive emotions, always negative emotions, anhedonia, detachment (two of seven)
- Unable to function or cause distress/Unattributed to a substance or another medical condition
- Month or more of symptoms
- Arousal and reactivity increased with two of the following: irritability, recklessness, hypervigilance, startling, concentration and sleep disturbances
- Symptoms present immediately and last up until a month after the event - longer = PTSD
- Note diagnostic or recurrence of a life-threatening disease can precipitate ASD/PTSD, especially with hematologic malignancies which may be sudden onset and have dramatic changes in clinical status
PTSD - diagnostic criteria
TRAUMA
- Traumatic event: witnessed or experienced or occurred to dearest or exposure repeatedly to its aversive details
- Re-experience one of following intrusion symptoms: memories, nightmares, flashbacks, psychological distress or physiological reaction to cues symbolising the traumatic event
- Avoidance of memories, thoughts, feelings of the traumatic event or its reminders
- Alterations in cognitions and mood negatively: forgetting, mislabelling, blaming, no positive emotions, always negative emotions, anhedonia, detachment (two of seven)
- Unable to function or cause distress/Unattributed to a substance or another medical condition
- Month or more of symptoms
- Arousal and reactivity increased with two of the following: irritability, recklessness, hypervigilance, startling, concentration and sleep disturbances
- Symptoms must last for over a month
- Note diagnostic or recurrence of a life-threatening disease can precipitate ASD/PTSD, especially with hematologic malignancies which may be sudden onset and have dramatic changes in clinical status
Management of Anxiety in the Palliative Care Setting
Optimize pain control and other interventions to restore control and ensure patients feel they have a safety net (e.g. Lifeline, support groups, volunteers, progressive muscle relaxation)
Consider psych (CBT, mindfulness based stress reduction, ACT, progressive relaxation strategies)
Benzos for short term or situational anxiety
- Use with caution in respiratory illness, in the elderly (associated with falls) and know they can exacerbate delirium and confusion
- Ideally, limit to acute panic attacks or treatment-related phobias
- If hepatic function is impaired, use lorazepam, odazepam, or temazepam (less dependent on liver function)
Panic disorder:
- Consider SSRIs for severe, frequent panic attacks, but initiate at half the dose as the initial side effects of nausea and dizziness can precipitate panic attacks
GAD or PTSD
- Consider SSRIs, SNRIs, or TCAs (all have anxiolytic effects)
- Buspirone can be used in GAD (non-benzo anxiolytic without sedative or cognitive side effects)
- May consider quetiapine, olanzapine in PTSD, though not first line in Palliative Care
Treatment of adjustment disorders
- Adjust the approach according to patient situation
- Psych intervention is first line (goal to reduce severity of stressors, enhance coping skills, and strengthen support system)
- Meds may be indicated as second line, and are best tailored to symptom profile
For patients who are not interested in psych care, medical team can alleviate distress through providing a supportive relationship, addressing pain and symptom control, and ensuring open communication
Treatment of adjustment disorders
- Adjust the approach according to patient situation
- Psych intervention is first line (goal to reduce severity of stressors, enhance coping skills, and strengthen support system)
- Meds may be indicated as second line, and are best tailored to symptom profile
For patients who are not interested in psych care, medical team can alleviate distress through providing a supportive relationship, addressing pain and symptom control, and ensuring open communication
Demoralization syndrome
- Not an official diagnostic category in the DSM
- Demoralization scale can be useful
- Generally, patients who feel that lives are pointless and meaningless
Symptoms
- Loss of meaning or purpose
- Loss of hope for a worthwhile future
- Sense of being trapped or pessimistic
- Feel like giving up
- Unable to cope with the predicament
- Socially isolated or alienated
- Potential for the desire to die
- Lasting > 2 weeks, may be comorbid or distant from other depressive disorders
Risk factors for desire for hastened death
- Depression
- Meaninglessness
- Hopelessness
- Functional limitations
- Poor social supports
- History of a psych disorder
- Delirium
- Alcohol or other substance abuse
Panic Disorder: Diagnostic Criteria
Abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which four or more of the following symptoms:
‘STUDENTS FEAR 3 C’s’
- Sweating
- Trembling or shaking
- Unsteadiness, dizziness, light headed or faint
- Depersonalisation or derealisation
- Excessive heart rate, palpitations
- Nausea or abdominal distress
- Tingling (numbness or paraesthesias)
- Shortness of breath or smothering
- Fear of dying, losing control or going crazy
- 3 C’s: chest pain, chills, choking
The other criteria can be remembered by using mnemonic ‘ABCD’.
- At least one attack followed by ≥1 month of one or both of:
- Behaviour to avoid having panic attacks, such as avoidance of unfamiliar situations or exercise.
- Concern or worry about the additional panic attack or their consequences. - Disturbance not attributable to effects of a substance or another medical or mental disorder.
Adjustment Disorder: Diagnostic Criteria
EMOTES
Emotional or behavioural symptoms within 3 months of onset of stressor(s) with:
- Marked distress in excess of what would be expected from exposure to the stressor (or)
- Occupational, academic or social functioning is significantly impaired
- Termination of symptoms within 6 months of termination of stressor or its consequences
- Exclusion of another mental disorder or exacerbation of pre-existing mental disorder ruled out
- Symptoms do not represent bereavement
Dysthymia: Diagnostic Criteria
Rule of Twos:
- 2 years of depressed mood
- 2 of 6 neurovegetative symptoms
- no more than 2 months without symptoms
Six neurovegetative symptoms can be remembered by mnemonic ‘SIGECHAL’
- Suicidal thoughts
- Interests decreased
- Guilt
- Energy decreased
- Concentration decreased
- Hopelessness
- Appetite disturbance (increased or decreased)
- Low self esteem
Major Depressive Disorder: Diagnostic Criteria
SIGECAPS (need 5/9 for at least 2 weeks) with depressed mood or loss of interest
- Suicidal thoughts
- Interests decreased
- Guilt
- Energy decreased
- Concentration decreased
- Appetite disturbance (increased or decreased)
- Psychomotor changes (agitation or retardation)
- Sleep disturbance (increased or decreased)
Mood disorder due to a general medical condition
Medical condition (biological mechanism) main direct cause of depressive symptoms
Substance-induced mood disorder
Effects of intoxication or withdrawal are the main cause of depressive symptoms
SSRIs Discontinuation Syndrome
HANGMAN: H - headache A - anxiety N - nausea G - gait instability M - malaise A - asthenia (fatigue) N - numbness (paresthesia)
