Psychiatric dimensions of palliative care

Mental health in chronic disease patients during the COVID-19 quarantine in Greece

Objective

To investigate the effect of the time spent on quarantine on distress, anxiety, depression, and somatization of chronic disease patients during the COVID-19 quarantine in Greece and the differences in these parameters between healthy individuals and chronic disease patients.

Method

The sample consisted of 943 healthy individuals and 163 patients (respiratory, autoimmune, cardiovascular, endocrine, patients with other diseases, and patients with more than one disease) completing sociodemographic assessments as well as the 4-Dimensional Symptom Questionnaire (4DSQ) during March 30, 2020 to May 3, 2020. Pearson's correlation was used to search for the association between time spent on quarantine and the 4DSQ subscales (distress, anxiety, depression, and somatization). Independent sample T-test and Glass's Δ were used for differences between healthy individuals and chronic disease patients in these subscales, an analysis also carried out between healthy individuals and all patient subgroups.

Results

No statistically significant correlations were noted between the 4DSQ subscales and the quarantine duration, both for the patient and the healthy individuals’ group. Chronic disease patients had significantly higher levels of distress (p = 0.001, Δ = 0.28) and somatization (p = 0.000, Δ = 0.47), but not there were no significant differences in anxiety (p = 0.098, Δ = 0.14) and depression (p = 0.052, Δ = 0.19). Concerning head-to-head comparisons between the healthy individuals’ group and each patient group, significantly higher scores in distress were found only for patients with respiratory diseases (p = 0.028, Δ = 0.42). Regarding somatization, significantly higher scores were noted for the healthy individuals’ group compared with patients with autoimmune diseases (p = 0.010, Δ = 0.62), respiratory diseases (p = 0.027, Δ = 0.42), other diseases (p = 0.003, Δ = 0.55), and more than one disease (p = 0.012, Δ = 0.60). No statistically significant differences were found in anxiety and depression.

Significance of results

The results of this study indicate that interventional programs for chronic disease patients during quarantine should focus on distress and somatization, not on anxiety and depression. Respiratory patients might have more supportive care needs compared with patients with other diseases.

The Prevalence and Risks for Depression and Anxiety in Hospice Caregivers

BACKGROUND

Depression and anxiety are common concerns for hospice caregivers.

OBJECTIVE

This study looked at the prevalence and variables associated with hospice caregiver depression and anxiety, as well as the relationship between the two conditions.

SUBJECTS

We did a secondary analysis of preexisting data.

MEASUREMENTS

Measures included the PHQ-9 and GAD-7.

RESULTS

Nearly one-quarter of caregivers were moderately to severely depressed, and nearly one-third reported moderate to severe symptoms of anxiety. Risk factors for both depression and anxiety included younger age and poorer self-rated global health. Depression-specific risk factors included being married and caring for a patient with a diagnosis other than cancer. The sole anxiety-specific risk factor identified was geographic location, as caregivers living in the Southeast were found to have greater anxiety than those in the Midwest.

CONCLUSION

Hospice providers' recognition of family caregivers as both coproviders and corecipients of care underscores the need to more fully assess and respond to depression and anxiety among caregivers.

Psychiatry trainees’ views and educational needs regarding the care of patients with a life-limiting illness

Objective:

People with a life-limiting physical illness experience high rates of significant psychological and psychiatric morbidity. Nevertheless, psychiatrists often report feeling ill-equipped to respond to the psychiatric needs of this population. Our aim was to explore psychiatry trainees’ views and educational needs regarding the care of patients with a life-limiting physical illness.

Method:

Using semistructured interviews, participants’ opinions were sought on the role of psychiatrists in the care of patients with a life-limiting illness and their caregivers, the challenges faced within the role, and the educational needs involved in providing care for these patients. Interviews were audiotaped, fully transcribed, and then subjected to thematic analysis.

Results:

A total of 17 psychiatry trainees were recruited through two large psychiatry training networks in New South Wales, Australia. There were contrasting views on the role of psychiatry in life-limiting illness. Some reported that a humanistic, supportive approach including elements of psychotherapy was helpful, even in the absence of a recognizable mental disorder. Those who reported a more biological and clinical stance (with a reliance on pharmacotherapy) tended to have a nihilistic view of psychiatric intervention in this setting. Trainees generally felt ill-prepared to talk to dying patients and felt there was an educational “famine” in this area of psychiatry. They expressed a desire for more training and thought that increased mentorship and case-based learning, including input from palliative care clinicians, would be most helpful.

Significance of Results:

Participants generally feel unprepared to care for patients with a life-limiting physical illness and have contrasting views on the role of psychiatry in this setting. Targeted education is required for psychiatry trainees in order to equip them to care for these patients.

Comparing counseling and dignity therapies in home care patients: A pilot study

Objective:

Several studies have successfully tested psychosocial interventions in palliative care patients. Counseling is the technique most often employed. Dignity therapy (DT) has recently emerged as a tool that can be utilized to address patients' needs at the end of life. The aims of our study were to examine the effects of DT and counseling and to offer useful information that could be put into practice to better meet patients' needs.

Method:

We developed a pilot randomized controlled trial at the Home Care Unit of the General University Hospital of Valencia (Spain). Some 70 patients were assigned to two therapy groups. The measurement instruments employed included the Patient Dignity Inventory (PDI), the Hospital Anxiety and Depression Scale (HADS), the Brief Resilient Coping Scale (BRCS), the GES Questionnaire, the Duke–UNC-11 Functional Social Support Questionnaire, and two items from the EORTC Quality of Life C30 Questionnaire (EORTC–QLQ–C30).

Results:

The results of repeated-measures t tests showed statistically significant differences with respect to the dimensions of dignity, anxiety, spirituality, and quality of life for both groups. However, depression increased in the DT group after the intervention, and there were no differences with respect to resilience. Therapy in the counseling group did not negatively affect depression, and resilience did improve. When post-intervention differences between groups were calculated, statistically significant differences in anxiety were found, with lower scores in the counseling group (t(68) = –2.341, p = 0.022, d = 0.560).

Significance of Results:

Our study provided evidence for the efficacy of dignity therapy and counseling in improving the well-being of palliative home care patients, and it found better results in the counseling therapy group with respect to depression, resilience, and anxiety.

Defending the indefensible? Psychiatry, assisted suicide and human freedom

The siege guns of the forces for change to euthanasia and assisted suicide laws have been pounding for decades, but the longstanding proscription on these practices has held out in all but a few jurisdictions. A few psychiatrists have enlisted with the challengers, but many remain on the battlements, defending the impermissibility of active assistance in dying. Given the long history of the separation of church and state and the significant secularisation of society; the recognition by the law of both acts and omissions as legal causes; lenient sentences for mercy killers; critiques of the "psychiatriatisation" of different aspects of life; and the consistency of public opinion, this recalcitrant stand bespeaks undercurrents and positions that are often by rationalised or camouflaged, and which call for exploration. In this paper, I examine connections between psychiatry and conceptualisations of harm, suffering and natural death; medicalisation, psychiatrisation and medical paternalism; decision-making capacity, rationality and diagnosis; recent legal developments; social pluralism; and religious intuitionism. I conclude that psychiatrists and the psychiatry profession, concerned as they are with enlarging the province of human freedom, should begin a more transparent rapprochement with those they would repel.

Spiritual beliefs near the end of life: a prospective cohort study of people with cancer receiving palliative care

Objectives

Despite growing research interest in spirituality and health, and recommendations on the importance of spiritual care in advanced cancer and palliative care, relationships between spiritual belief and psychological health near death remain unclear. We investigated (i) relationships between strength of spiritual beliefs and anxiety and depression, intake of psychotropic/analgesic medications and survival in patients with advanced disease; and (ii) whether the strength of spiritual belief changes as death approaches.

Methods

We conducted a prospective cohort study of 170 patients receiving palliative care at home, 97% of whom had a diagnosis of advanced cancer. Data on strength of spiritual beliefs (Beliefs and Values Scale [BVS]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), psychotropic/analgesic medications, daily functioning, global health and social support were collected at recruitment then 3 and 10 weeks later. Mortality data were collected up to 34 months after the first patient was recruited.

Results

Regression analysis showed a slight increase in strength of spiritual belief over time approaching statistical significance (+0.16 BVS points per week, 95% CI [−0.01, 0.33], p = 0.073). Belief was unrelated to anxiety and depression (−0.15 points decrease in HADS for 10 points increased in BVS (95% CI [−0.57, 0.27], p = 0.49) or consumption of psychotropic medication). There was a non-significant trend for decreasing analgesic prescription with increasing belief. Mortality was higher over 6 months in participants with lower belief at recruitment.

Conclusion

Results suggest that although religious and spiritual beliefs might increase marginally as death approaches, they do not affect levels of anxiety or depression in patients with advanced cancer. © 2013 The Authors. Psycho-Oncology published by John Wiley & Sons, Ltd.

Depression and anxiety in palliative care inpatients compared with those receiving palliative care at home

OBJECTIVE

This study compared the prevalence of anxiety and depression as measured on the Hospital Anxiety and Depression Scale (HADS) in palliative care patients being treated at home with those being treated as inpatients.

METHOD

The participants were palliative care patients being treated at home (n = 46) and palliative care inpatients (n = 46). Subjects were assessed for functionality on the Karnofsky Performance Status Scale (KPS) and anxiety and depression were measured on the HADS.

RESULTS

The results showed that ~20% of all patients were depressed and anxious as measured on the HADS, regardless of the cutoff criteria. There was no significant difference in depression and anxiety between the two groups when socioeconomic status and functionality were controlled for. Functionality, as measured on the KPS, was uniquely a predictor of depression, and younger patients were shown to have greater anxiety.

SIGNIFICANCE OF RESULTS

The results suggest that home-based palliative care patients and palliative care inpatients should receive equal psychological support, and that clinicians need to be aware of the psychological vulnerability of younger and less-functional patients. The prevalence of depression and anxiety indicates that all palliative care patients should be screened for psychological distress, to identify those who need further assessment and treatment.

Association between symptoms and their severity with survival time in hospitalized patients with far advanced cancer

OBJECTIVE

To assess the significance of symptoms and their severity for predicting survival of hospitalized patients with far advanced cancer.

METHODS

Two hundred fifty-six patients with far advanced cancer at the Cancer Center of Tongji Hospital, China were assessed by the Chinese version of the M.D. Anderson Symptom Inventory (MDASI-C). A Cox regression model was used to determine symptoms that could predict survival time. The log-rank test was used to compare the survival of patients accompanied by significant symptoms at different intensities.

RESULTS

Median survival was 49 days. Fatigue was the most common and severe symptom, followed by lack of appetite, disturbed sleep, and pain. Multivariate analysis showed that fatigue, shortness of breath, lack of appetite, and feeling sad were independent prognostic factors for survival time (p  < 0.05), with a hazard ratio of dying of 1.39, 1.13, 1.33, and 1.16, respectively. The survival time for patients with different intensities of the four symptoms showed significant differences (p  <  0.01).

CONCLUSIONS

Fatigue, lack of appetite, feeling sad, and shortness of breath could be predictive factors for survival time of hospitalized patients with far advanced cancer. The more severe these symptoms are, the shorter will be survival time.

Palliative care for the cancer patient

Palliation of symptoms to optimize QOL is the foundation of cancer care regardless of stage of disease or level of anticancer treatment. Patients commonly experience pain, constipation, nausea, vomiting, dyspnea, fatigue, and delirium. Many valid clinical tools are available to the primary care clinician to screen for symptoms, assess severity, measure treatment response, and elicit the patient's subjective symptom experience. Although there is limited evidence regarding the relative efficacy of symptom interventions from randomized controlled trials, clinical practice guidelines are available.

Do rates of mental disorders and existential distress among advanced stage cancer patients increase as death approaches?

OBJECTIVE

To determine whether the prevalence of mental disorders and related factors increase as advanced cancer patients get closer to death.

METHOD

Baseline, cross-sectional data from 289 patients who were assessed prior to their death as part of a multi-site, longitudinal, prospective cohort study of advanced cancer patients. Major depressive disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV Axis I Disorders. Other factors examined included existential well-being, patient grief about their illness, physical symptom burden, terminal illness acknowledgment, peacefulness, and the wish to live or die.

RESULTS

Closeness to death was not associated with higher rates of mental disorders. Patients closer to death exhibited increased existential distress and physical symptom burden, were more likely to acknowledge being terminally ill, and were more likely to report an increased wish to die.

CONCLUSION

Results do not provide support for the common clinical assumption that the prevalence of depressive and anxiety disorders increases as death nears. However, patients' level of physical distress, acknowledgment of terminal illness, and wish to die, possibly reflecting acceptance of dying, increased as death approached. Longitudinal studies are needed to confirm individual changes in rates of mental disorder as patients approach death.

The changing causal foundations of cancer-related symptom clustering during the final month of palliative care: a longitudinal study

BACKGROUND

Symptoms tend to occur in what have been called symptom clusters. Early symptom cluster research was imprecise regarding the causal foundations of the coordinations between specific symptoms, and was silent on whether the relationships between symptoms remained stable over time. This study develops a causal model of the relationships between symptoms in cancer palliative care patients as they approach death, and investigates the changing associations among the symptoms and between those symptoms and well-being.

METHODS

Complete symptom assessment scores were obtained for 82 individuals from an existing palliative care database. The data included assessments of pain, anxiety, nausea, shortness of breath, drowsiness, loss of appetite, tiredness, depression and well-being, all collected using the Edmonton Symptom Assessment System (ESAS). Relationships between the symptoms and well-being were investigated using a structural equation model.

RESULTS

The model fit acceptably and explained between 26% and 83% of the variation in appetite, tiredness, depression, and well-being. Drowsiness displayed consistent effects on appetite, tiredness and well-being. In contrast, anxiety's effect on well-being shifted importantly, with a direct effect and an indirect effect through tiredness at one month, being replaced by an effect working exclusively through depression at one week.

CONCLUSION

Some of the causal forces explaining the variations in, and relationships among, palliative care patients' symptoms changed over the final month of life. This illustrates how investigating the causal foundations of symptom correlation or clustering can provide more detailed understandings that may contribute to improved control of patient comfort, quality of life, and quality of death.

Management of common neurologic symptoms in pediatric palliative care: seizures, agitation, and spasticity

Palliative care for children is complex and focuses on patients' comfort. Some of the most troublesome symptoms as patients approach the end of life are seizures, agitation, and spasticity. Many doctors caring for children at the end of life are uncomfortable or untrained in managing these symptoms in children. Our goal is to help physicians recognize and treat these neurologic symptoms optimally.

Cancer pain and anxiety

Anxiety and pain can be understood with a multidimensional framework that accounts for somatic, emotional, cognitive, and behavioral aspects of these conditions. Patients who have cancer or treatment-related pain are more likely to be anxious than cancer patients without pain. Patients with cancer pain and anxiety cause difficult diagnostic dilemmas because some degree of anxiety is a normal response to having a severe medical illness. Furthermore, the somatic symptoms of anxiety often overlap with symptoms related to underlying disease processes or treatment effects. The degree of disruption in a patient's life often is the critical factor in distinguishing normal from maladaptive anxiety. Making an accurate diagnosis will help guide anxiety treatment and screening instruments can facilitate the recognition of those patients in need of further assessment. The relationship between pain and anxiety is complex and bidirectional, with interactions occurring on physiologic and psychologic levels. There are a variety of psychopharmacologic, psychotherapeutic, and complementary/alternative treatments available. A comprehensive approach to care includes these approaches in an individualized way. Terminal sedation is examined as a compassionate option for relieving intractable distress at the end of life.