Psychiatric Distress in Chronic & Terminal Illness Barb Henry, ARNP, MSN Psycho-Oncology Consultants, LLC & The University of Cincinnati Central Clinic
University of Cincinnati Central Clinic www.centralclinic.org
Previous Oncology Experience- 6 years as psychiatric provider for Oncology Hematology Care (OHC) www.oncologyhematologycare.com 41 Physicians and 2 Nurse Practitioners in 17 offices in OH, IN, Northern KY providing chemotherapy, radiation therapy, bone marrow biopsy, gynecologic services and diagnostic testing
& for the Jewish Hospital Blood & Marrow Transplant Program
Learning Objectives: Understand psychiatric distress, emotional and survivorship issues in people with chronic & terminal illness. Learn effective communication in helping clients deal with these issues. Understand possible benefits and side effects of psychotropic medications including: antidepressants, anti-anxiety agents, sleep agents, & anti-psychotic medications.
www.laf.org
Psychiatric Issues of Chronic & Terminal Illnesses Depression/Grieving, Re-living Previous Loss Anxiety Role Changes, possible Family Dysfunction Caregiver becoming Care-Receiver Financial Concerns Concerns about future of children, grandchildren, the remaining spouse Concerns about Death, Afterlife Saying Goodbye/Spirituality
NCCN Guidelines for Distress for Oncology staff & patients Emotional Distress-problems with partner, children, worry, fears, sadness, depression, nervousness, loss of interest in usual activities, practical problems with work, housing, insurance, school, transportation, child care Related Physical Distress: pain, nausea, fatigue, sleep, getting around, bathing/dressing, breathing, mouth sores, eating, indigestion, constipation, diarrhea, changes in urination, fevers, skin dry/itchy, nose dry/congested, tingling in hands/feet (peripheral neuropathy), feet swollen, sexual, appearance, memory concentration (a.k.a. chemo-brain ) Measurement tools and treatment recommendations
What to do with information obtained from such tools?!... Practical Problems-helpful to have social work staff and/or case management professionals Family/Emotional Problems-helpful to have social work, psychology, prescribing psychiatric staff who can effectively help with issues Spiritual/Religious Concerns-helpful to have effective Spiritual Care Program/staff Physical Problems-managed well by hospice staff & medical professionals
What Can Hospice Professionals Do to Make it Easier? Be mindful of the client s previous negative experiences with medical professionals Agency Milieu & should include user friendly receptionists and phones Transference with Oncologists/MD simportance of words & body language* Education and support by nurses
Metastatic Prostate Ca, Retirement, Loss of Golden Years
Communication Get to know your patient as an individualtheir individual personalities, likes/dislikesare they private vs. social, where do/did they work, family and support people, resources Talk to them in ways you would want to hear if you were in their shoes, find out what they ve been told about their disease, treatment & prognosis Your experience tells you if someone is having a harder time emotionally than most, that s when to intervene
Psychological Issues of Chronically/Terminally Ill Patients Patients often experience depression and/or anxiety even if they never had this problem before. The chronic/terminal illness experience often triggers grieving of previous losses. Antidepressant and/or anti-anxiety medication can be helpful, even if the patient has never needed psychotropic medications in the past.
Metastatic Colon Ca, Parenting Grandchildren & Dieing
Brain chemicals that effect mental health Serotonin (5HT) is a neurotransmitter effecting digestion as well as depression; depletion of Serotonin has been found to cause depression. Many subtypes of 5HT, SSRI s work on 5HT6&7-depression associated ones. Norepinephrine, Epinephrine & Dopamine are catecholamines which exhibit excitatory or inhibitory actions on the CNS & peripheral nervous systems. A depletion of these can cause depression, and exaggerated function of dopamine can cause schizophrenia. Reuptake Inhibition of any of these neurotransmitters can improve depression by allowing more of the substance to remain in the synapse where it is depleted in depressed patients. There are also hormonal influences on mental health (too extensive to address in this presentation)
General Rules/Concerns with Psychotropic Medications Patients should take them for at least 6 months until the immediate stressor is less; can taper off or continue the drug for the rest of their life* Concerned about sexual side effects* Concern that antidepressants will take too long to work* Concern about addiction*
More General Rules/Concerns with Psychotropic Medications Not all patients with cancer need psychotropic medications Most commonly we use antidepressants, anti-anxiety medications, sleep medications, occasionally anti-psychotics or stimulants Narcotics and some anti-nausea medications for patients with cancer have psychological effects/side effects
Possible Psychiatric Illness in Chronic/Terminally Ill Post Traumatic Stress Disorder Depression-Low Self-Esteem, Sexuality Issues Anxiety Grief Reactions Personality Disorders/Traits Chemical Dependency Family Dysfunction Sleep Disorders
Dieing with Dignity
Depression When appropriate feelings of depression in response to the diagnosis, prognosis, and treatment do not eventually dissipate Symptoms of clinical depression mimic symptoms of chronic/terminal illnesssleeplessness, weight loss or gain, fluctuations in mood, severe anxiety and sadness that won t go away, suicidal thinking* Can occur even in those who ve never had clinical depression in the past When your patient or family member tells you they are depressed, or different from their prediagnosis self
Antidepressants-SSRI s Generic Escitalopram Citalopram Sertraline Buproprion Nefazedone Fluoxetine Paroxetine Mirtazepine Nefazedone Brand Lexapro Celexa Zoloft Wellbutrin Effexor Prozac Paxil Remeron Serzone
Tricyclic Antidepressants Generic Amitriptyline Desipramine Doxepin Imipramine Nortriptyline Desyryl Brand Elavil Norpramin Sinequan Tofranil Pamelor Trazedone (MAO Inhibitors) Phenylzine Sulfate Tranylcypromine Sulfate Marplan-no longer made Nardil Parnate
Anxiety Easily startled, hyper-alert Obsessive worry Excessive fears Nightmares Spending most of the day thinking about the illness/death, treatment, researching Difficulty falling or staying asleep Frozen facial expression, psychomotor agitation, difficulty speaking, putting thoughts together, excessive tearfulness
Death without Spirituality
Anti-Anxiety: Benzodiazepines Generic Lorazepam Alprazolam Clonazepam Diazepam Chlordiazepoxide Chlorazepate Oxazepam Other Agents Buspirone Propanolol Brand Ativan Xanax Klonopin Valium Librium Tranxene Serax Buspar Inderol
Sedative/Hypnotics: Generic Brand Name Flurazepam Temazepam Triazolam Other Agents Zalepion Zolpidem Eszopiclone Dalmane Restoril Halcion Sonata Ambien Lunesta
Antipsychotic Medications Generic Brand Name Miscellaneous Antipsychotics Risperidone Olanzapine Quitiapine Fumarate Haloperidol Aripiprazole Ziprazidone Risperdal Zyprexa Seroquel Haldol Abilify Geodon Phenothiazines Prochlorperazine Chlorpromazine HCl Thioridizine Perphenazine Compazine Thorazine Mellaril Trilafon
Other Psychotropic Medications Stimulants/ADHD Meds: Methylphenidate- Ritalin, Concerta, Dexedrine, Adderall, etc. Atemoxetine-Strattera-Norepinephrine Reuptake Inhibitor-used for ADHD Mood Stabilizers: Lithium, Depakote, Tegretol, Lamictal, Topamax, Neurontin Non-psychotropics that effect mental health: Steroids, Compazine, Marinol, Voriconazole, others
Death of a Young Person
Psychotherapy for Chronically/Terminally Ill Can be an effective technique just listen It is helpful if the therapist has some knowledge of chronic/terminal illness and treatment Psychosocial issues that existed prior to the illness are magnified and can be the focus of the therapy Preparing for Death Grieving
Prevalence of Psychological Distress with Cancer Researchers at Dana Farber & elsewhere have found an incidence of 30% of patients with Cancer had significant psychological distress Nearly 14% (from the D.F. sample) also reported having suicidal thoughts, a rate much higher than that seen in the general population
Questions/Cases?...
Self-Care & Balance of Work & Play