Response to Henderson et al., Staffing a Specialist Palliative Care Service, a Team-Based Approach: Expert Consensus White Paper (DOI: 10.1089/jpm.2019.0314)

Increasing Awareness and Access to Integrated Behavioral Health and Palliative Care: An Introduction to the American Journal of Hospice and Palliative Medicine's

Mental health symptoms are common in the general population and are overrepresented in patients receiving palliative care and hospice services. This introduction to the special issue on Mental Health in Palliative Care and Hospice highlights the ongoing need for research and training to prepare our palliative care workforce to address the concerns of patients experiencing serious illness and mental health concerns. Multilevel approaches are needed to enhance understanding of mental health needs among people with serious illness. Public health outreach is needed within our communities, targeted support is needed for family caregivers, and structured training for palliative care and hospice clinicians is needed to enhance competent mental health in these settings.

Understanding and Addressing Mental Health Disparities and Stigma in Serious Illness and Palliative Care

Patients receiving palliative care experience stigma associated with their illness, personal identity, and healthcare utilization. These stigmas can occur at any stage of the disease process. Varying stigmas combine to cause palliative care patients to feel misunderstood, contribute to treatment barriers, and further negative stereotypes held by clinicians. Stigma surrounding palliative care patients stems from complex intersections of varied access to resources, familial and physical environment, socioeconomic status, mental health and disorders, and identity characteristics. This article examines the relationship between mental health stigma and palliative care through three pathways: stigma and barriers existing within healthcare, the tendency of this stigma to undermine social support, and the deferral of treatment-seeking in response to stigma. Recommendations to address and diminish stigmatization are presented, including advocacy, increased research and assessment, and contextual and intersectional awareness. Clinicians are also encouraged to turn to their colleagues for peer support and team-based care.

Priming the Palliative Psychology Pipeline: Development and Evaluation of an Undergraduate Clinical Research Training Program

Psychology adds value to palliative care research and practice, but palliative psychology training programs are underdeveloped, particularly prior to advanced graduate and post-doctoral training. The investigation aimed to examine the feasibility of developing an undergraduate clinical research training program focused on the application of palliative psychology to cancer care. Analyses described and examined predictors of trainee performance and post-graduate outcomes. Retrospective analyses of administrative data tracking trainee characteristics (degree programs and tracks, qualifications, and demographics), research trainee performance (satisfactory participation, training duration, scientific output, supervisor ratings, and overall performance), and post-graduate degree programs. The population included all undergraduate trainees in a cancer-focused palliative psychology research lab from inception in 2013 through 2020 at a US research-intensive university. Trainees (N = 25) typically majored in psychology (72.0%) or neuroscience (28.0%), often with second majors. The average participation in the lab was 3.4 semesters. Overall, 92.0% of trainees earned a conference abstract, 56.0% earned a publication, and 72.0% went on to a post-graduate degree program, most commonly psychology PhD, MD, or nursing programs. Trainees enrolling in psychology PhD programs were more likely than other trainees to have been on the pre-psychology PhD track (P < .001) and had higher overall research performance (P = .029), including higher supervisor ratings (P = .008) and higher scientific output (P = .019). This demonstration study provides evidence for the feasibility and beneficial impact of an undergraduate palliative psychology clinical research training program as an early component of cancer educational training. Findings support calls for the development and evaluation of novel palliative training programs worldwide.

Anxiety, depression, and end-of-life care utilization in adults with metastatic cancer

OBJECTIVE

End-of-life care for patients with cancer is often overly burdensome, and palliative and hospice care are underutilized. The objective of this study was to evaluate whether the mental health diagnoses of anxiety and depression were associated with variation in end-of-life care in metastatic cancer.

METHODS

This study used electronic health data from 1,333 adults with metastatic cancer who received care at two academic health centers in Louisiana, USA, and died between 1/1/2011-12/31/2017. The study used descriptive statistics to characterize the sample and logistic regression to examine whether anxiety and depression diagnoses in the six months before death were associated with utilization outcomes (chemotherapy, intensive care unit [ICU] visits, emergency department visits, mechanical ventilation, inpatient hospitalization, palliative care encounters, and hospice utilization), while controlling for key demographic and health covariates.

RESULTS

Patients (56.1% male; 65.6% White, 31.1% Black) commonly experienced depression (23.9%) and anxiety (27.2%) disorders within six months of death. Anxiety was associated with an increased likelihood of chemotherapy (odds ratio [OR] = 1.42, p = 0.016), ICU visits (OR = 1.40, p = 0.013), and inpatient hospitalizations (OR = 1.85, p < 0.001) in the 30 days before death. Anxiety (OR = 1.95, p < 0.001) and depression (OR = 1.34, p = 0.038) were associated with a greater likelihood of a palliative encounter.

CONCLUSIONS

Patients with metastatic cancer who had an anxiety disorder were more likely to have burdensome end-of-life care, including chemotherapy, ICU visits, and inpatient hospitalizations in the 30 days before death. Depression and anxiety both increased the odds of palliative encounters. These results emphasize the importance of mental health considerations in end-of-life care.