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Palliative > Psychiatric Aspects of Care > Flashcards

Psychiatric Aspects of Care Flashcards

1
Q

Prevalence and risk factors for anxiety/depression in PC

A
  • 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)
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2
Q

Why is younger age associated with increased risk of depression

A
  • 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
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3
Q

Clinical significance of untreated anxiety

A
  • 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
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4
Q

Clinical significance of untreated depression

A
  • 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
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5
Q

Is sadness a normal part of the dying process?

A
  • 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
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6
Q

Desire for hastened death

A
  • 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
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7
Q

Suicidality in Palliative patients - risk factors

A
  • 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
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8
Q

Risk assessment for suicide

A

Suicide Assessment Five Step Evaluation and Triage (SAFE-T)

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9
Q

Modifiable factors that may contribute to depression

A

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
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10
Q

Pharmacological treatments for depression in palliative care

A

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
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11
Q

Psychosocial treatments for depression in palliative care

A
  • 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
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12
Q

GAD - diagnostic criteria

A

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

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13
Q

Acute stress disorder - diagnostic criteria

A

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
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14
Q

PTSD - diagnostic criteria

A

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
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15
Q

Management of Anxiety in the Palliative Care Setting

A

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
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16
Q

Treatment of adjustment disorders

A
  • 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

17
Q

Treatment of adjustment disorders

A
  • 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

18
Q

Demoralization syndrome

A
  • 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
19
Q

Risk factors for desire for hastened death

A
  • Depression
  • Meaninglessness
  • Hopelessness
  • Functional limitations
  • Poor social supports
  • History of a psych disorder
  • Delirium
  • Alcohol or other substance abuse
20
Q

Panic Disorder: Diagnostic Criteria

A

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’.

  1. 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.
  2. Disturbance not attributable to effects of a substance or another medical or mental disorder.
21
Q

Adjustment Disorder: Diagnostic Criteria

A

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
22
Q

Dysthymia: Diagnostic Criteria

A

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
23
Q

Major Depressive Disorder: Diagnostic Criteria

A

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)
24
Q

Mood disorder due to a general medical condition

A

Medical condition (biological mechanism) main direct cause of depressive symptoms

25
Q

Substance-induced mood disorder

A

Effects of intoxication or withdrawal are the main cause of depressive symptoms

26
Q

SSRIs Discontinuation Syndrome

A 
HANGMAN: 
H - headache
A - anxiety
N - nausea
G - gait instability
M - malaise
A - asthenia (fatigue)
N - numbness (paresthesia)

Palliative (71 decks)

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