PSYCHOLOGICAL PROBLEMS IN PALLIATIVE CARE: DEPRESSION, ANXIETY

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PSYCHOLOGICAL PROBLEMS IN PALLIATIVE
CAREDEPRESSION, ANXIETY CONFUSION

• DR NOREEN CHAN
• Senior Consultant, Dept of Haematology-Oncology,
  NUHS
• Visiting Consultant, Dover Park Hospice

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Normal, Psychological or Psychiatric?

• I am already so upset about having cancer. Why
  do I have to see psychiatrist? I am not mad!
• Wont you feel the same way if you are in my
  position?
• Challenge when is it abnormal?

Adapted from Dr Tang Hui Kheng
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Spectrum of Psychiatric Disorders
50
80
100

• Psychosocial Collaborative Oncology Group Report

0
Normal Responses to Cancer Day to day
stress Crisis
Adjustment Disorders With depressive Anxiety
symptoms
Depression
Delirium
Anxiety D/O
Personality D/O
Others
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The periods of distress
Patients perspective of heightened
distress McCormick Conley 1995
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CLINICAL SPECTRUM

• Short-lived psychoemotional symptoms may occur
  after periods of stress
• What is important is the severity and persistence
  of symptoms

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DEPRESSION
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DEPRESSION

• Median prevalence of major depression in advanced
  cancer 15 (5-26)
• Often undiagnosed or underdiagnosed
• Low mood understandable
• Some physical symptoms appetite change,
  lethargy, sleep disturbance common in advanced
  cancer

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The Depression Continuum

• Normal (grief/ stress reaction)
• Adjustment Disorder
• Minor depression/ Sub-clinical
• Major Depression (functional/ organic)

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DIAGNOSIS OF DEPRESSION

• According to DSM-IV criteria, need either
  Depressed Mood or Anhedonia (loss of interest)
  plus at least four other symptoms on list
• Weight change
• Sleep disturbance
• Psychomotor problems
• Lack of energy
• Excessive guilt
• Poor concentration
• Suicidal ideation

But some of these physical symptoms also occur in
advanced cancer and other diseases. How do we
tell the difference???
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Description The following collectively suggest a
depressive illness Sustained low mood Sustained
loss of pleasure in life Hopelessness/worthlessnes
s Excessive guilt Suicidal thoughts / acts
Evaluation of low mood
Psychological factors Risk factors for
depression Past depression Coping
style/personality Lack of social support Reaction
to diagnosis/disability Unresolved
concerns Unrelieved symptoms Bereavement
Differential diagnosis Adjustment
reaction Demoralised Sadness Grief Depression
Low Mood
Physiological causes Drugs Cancer Metabolic Endocr
ine Cerebral disorder
From R Twycross A Wilcox (1997) Symptom
Management in Advanced Cancer
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Depression Causes

• Cancer-related
• Persistent symptoms eg pain
• Increased physical impairment or discomfort
• Treatment-related eg radiotherapy, chemotherapy,
  drugs such as corticosteroid,
• Endocrine/Metabolic abnormalities e.g .
  hypothyroidism, hypercalcemia,
• Types Pancreatic, head neck cancer

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Causes of Depression (contd)

• B. Others
• History of depression, suicide attempts
• Family history of depression (genetic
  vulnerability)
• History of alcoholism or drug abuse
• Concurrent Life stressors e.g. going through
  divorce, financial strain

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DEPRESSION - Management

• Drug treatment
• Psychosocial intervention
• Psychological therapy

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Management of Depression

• Medications
• A. Selective Serotonin Reuptake Inhibitors SSRI
• Fluoxetine 20mg eom, 10mg om 20mg OM
• Fluvoxamine 25mg on 50mg ON
• Escitalopram 5mg om 10mg OM
• Sertraline 25mg on 50mg ON
• Start at half dose as listed above, slowly
  increase to full dose when tolerated after 1
  week.
• Drug interactions, side effect profiles
• (nausea, epigastric discomfort, dry mouth,
  constipation, low sodium)

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Management of Depression (contd)

• B. Tricyclics rarely used nowadays
• Amitriptylline
• Dothiepin
• Risk in overdose, side effects (esp constipation)
• Neuropathic pain
• C. Psychostimulants
• methylphenidate (controlled drug more rapid
  onset, energizing, severe psychomotor slowing
  side effects cardiovascular)

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Management of Depression (contd)

• Other antidepressants
• Mirtazapine (sedating, increase appetite when
  SSRIs not favourable)
• Venlafaxine (helpful for hot flushes, may
  increase BP)
• Benzodiazepines (complement antidepressants,
  short term use for sedation and associated
  anxiety symptoms)

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Non-Pharmacological Management of Depression

• Psycho-social intervention
• Family therapy
• Practical assistance e.g. financial support
• Psychological treatment
• Supportive counselling/grief counselling
• Cognitive-Behavioural therapy
• Solution-focused therapy
• Relaxation/guided imagery/hypnosis

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ANXIETY
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Anxiety.as a Symptom

• 3 components of Anxiety
• Physical - autonomic hyperactivity, insomnia,
  loss of appetite
• Mood - anxiety, irritable, vigilance,
• Cognitive - Impaired concentration, negative
  thinking, excessive worrying
• Usually, pt will only talks about the physical
  component e.g. chest pain, cannot sleep

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Panic Attacks
Shortness of breath
STRESS
Breathing Muscles tire even more
Anxiety starts
Breathing faster
Breathing Becomes even more rapid
Breathing Muscles tire
Anxiety increases
Shortness of breath increases
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Anxiety causes

• Disease and Treatment-related Anxiety
• Unpleasant treatment experience
• Poor pain control
• Related metabolic disturbances e.g hypoglycemia
• Delirium
• Sepsis
• Substance-induced Anxiety
• Corticosteroids dexamethasone, prednisolone
• Metoclopramide, prochlorperazine (antiemetic
  neuroleptics)
• Bronchodilators
• Withdrawals from benzodiazepines, opioids,
  alcohol

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Anxiety causes

• Reactive anxiety/adjustment
• Awareness of condition/prognosis
• Fears, uncertainty of death
• Conflicts
• Psychiatric
• Gen. Anxiety Disorder, Panic Disorder, Phobic
  Disorder, PTSD
• Agitated Depression
• Psychotic Disorder
• Anxious Personality Disorder

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ANXIETY - Management

• Anxiety can be infectious!
• Correct the correctable
• Relieve pain other distressing symptoms
• Adjust drugs
• Psychological methods
• Explanation
• CBT, relaxation therapy
• Counselling

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ANXIETY Drug Treatment

• Benzodiazepines
• Short acting e.g. alprazolam
• Intermediate acting e.g. lorazepam
• Long acting e.g. diazepam
• Antidepressant
• Sedating drug if insomnia e.g. fluvoxamine
• Antipsychotics
• If patient psychotic
• If agitated delirium present
• If anxiety worsened by benzodiazepines

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DELIRIUM
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DELIRIUM

• Is an acute confusional state
• Characterised by mental clouding poor
  attention, disorientation, cognitive impairment
• Fluctuating conscious level
• Common in hospitalised elderly patients
• Should be distinguished from dementia which is
  chronic

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DELIRIUM

• Commonly multi-factorial in advanced cancer
• Depression, anxiety, dementia, visual/hearing
  impairment, urinary retention, faecal impaction
  may aggravate / contribute
• May be hyperactive (agitated), hypoactive
  (lethargic) or mixed
• Investigation of underlying cause should be
  appropriate to the patients stage of disease and
  prognosis

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DELIRIUM Clinical Features

• Early symptoms -
• transient periods of disorientation esp time
  (confused)
• irritability , restless
• withdrawal , refusal to talk
• forgetfulness that was not previously present

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DELIRIUM Clinical Features

• Late symptoms
• disorientated to time, place and person
• delusion often paranoid
• hallucinations - visual , auditory

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DELIRIUM Some Causes

• Intracranial pathology
• Metabolic e.g. organ failure, electrolyte
  disturbance
• Sepsis
• Drugs
• Drug withdrawal
• Circulatory e.g. dehydration
• But often patients are too frail for a thorough
  search for causes

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DELIRIUM - Management

• Treatment of the cause
• Including review of medications
• General measures
• Well-lit, calming environment
• Try to avoid restraints
• Drug treatment
• Haloperidol is the drug of choice e.g. 1-5mg 8
  hourly PO
• Severely agitated or psychotic patients may
  require 2.5-10mg sc stat

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Haloperidol in Delirium
AD Macleod. The management of delirium in hospice
practice. EJPC 1997 4(4) 116-120
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DELIRIUM Other Drug Management

• Other Anti-Psychotics
• Risperidone, Olanzepine, Chlorpromazine
• Benzodiazepines
• May be required if patient is very agitated and
  restless
• Lorazepam, Diazepam, Midazolam
• Caution is required in elderly