Download Palliative Psychiatry - Integration of Psychiatry into Primary Health

and Interventions
Gary Rodin MD FRCPc
Professor of Psychiatry , University of Toronto
Head, Department of Psychosocial Oncology and Palliative Care
Princess Margaret Cancer Centre
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An experience
A symptom complex
A continuum of distress
disorder
a final common pathway
of distress
A disorder
A neurobiological state
Rodin et al 2009
Medical and Demographic Factors
Age and Gender
Living situation
Medical diagnosis and treatment
Personal/family history of psych illness
Psychiatric co-morbidity
depression/psychiatric illness
Disease-Related
Factors
Biological Mechanisms
Physical suffering &
disability
Stage of disease
Proximity to death
Non-pathological sadness
Fitzgerald et al 2013
Psychosocial
Factors
Social support
Attachment security
Self-esteem
Spiritual well-being
Economic hardship
Caregiving burden
Adjustment disorder
Major depression
Mild Moderate Severe
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Adversely affects:
 Quality of life
▪ Grassi et al, 1996
 Severity of Physical
symptoms
▪ Fitzgerald et al 2013
 Treatment compliance
▪ Colleoni et al, 1996
 Will to live
▪ Rodin et al, 2007
 Family distress
▪ Braun et al, 2007
 Health care utilization
▪ Prieto et al, 2002
▪ Lo et al, 2011
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Detection by physicians of self-reported distress:
 2642 patients in cancer aftercare program in
Germany
▪ Mild to severe distress on psychosocial
questionnaire detected by physicians in 10% of
cases
▪ Werner et al 2010
 2,325 primary healthcare recipients completed the
General Health Questionnaire (GHQ)
▪ Physicians (n=67) identified GHQ-distress in 42 %
of cases
 Rabinowitz et al 2005
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Systemic factors
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 Case volumes
 Lack of privacy
 Lack of psychosocial
 Perceived stigma/ lack of
interest of medical staff
 Fear of emotions
 Lack of awareness
treatment resources
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Medical staff factors
Patient Factors
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Diagnostic Uncertainty
 Lack of training in
 Confounding Symptoms of
emotional enquiry
 Lack of time
 Discomfort with
emotions
depression and medical
illness
▪ e.g. anorexia, weight loss,
fatigue, sleep disturbance
40
35
30
25
% of
20
sample
patients
spouse
15
10
5
0
BDI>15
Depression
BHS>8
Hopelessness
SAHD>9
Braun et al JCO 2007
Rodin et al: SSM 2009
Lo et al JCO 2010l
Desire for Hastened Death
The Distribution of Depressive Symptoms
in Patients with Metastatic Cancer
50
46.9
45
40
35
30.9
30
25
%
Sample
20
13.2
15
10
7.6
5
1.4
0
BDI<9
BDI 9-15
BDI 16-21
BDI 22-30
BDI>30
Miller et al Soc Psy Epidemiology 2011
Predicted Depressive Symptoms
for Individuals Differing in Physical Burden and Psychosocial
Vulnerability
over the last year of life.
Lo C et al. JCO 2010;28:3084-3089
Lo et al 2010
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Goal:
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Administered electronically to cancer outpatients q 2-3
months:
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•
•
•
•
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Edmonton Symptom Assessment System (ESAS) for physical symptoms
(each visit)
Social Difficulties Inventory (SDI-21) for practical concerns
Patient Health Questionnaire (PHQ-9) for depression
Generalized Anxiety Subscale (GAD-7) for anxiety
Desire for support
Suicidal intention
•
Print-out of summary scores for patient and clinic staff
•
Response Algorithm
•
Download into electronic record
System
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High sensitivity and specificity of
• ESAS-A > 3 for anxiety
• ESAS-D>2 for depression
30
25
20
% sample
15
Severe
Moderate
10
5
N- 1215
0
Depression
Anxiety
Bagha ..Li
2012
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Ideation:
 Thoughts that you would be better off dead, or of hurting
yourself in some way
▪ 5.8% endorsed this item
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Intent (in those with ideation)
 “Is there a chance you would do something to end your life ?”
▪ 7.1% endorsed this item
 Leung, Li .. Rodin et al, 2014
 Suicidal ideation
▪
▪
▪
▪
▪
more recent cancer dx
personal or family hx depression
more difficulty making treatment decisions
more social difficulties
Symptoms of , anxiety, depression and physical
distress
 Suicidal intention
▪ male sex
▪ difficulty with treatment decisions and self-care
-Leung, Li .. Rodin et al, 2014
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Depression has been postulated to be
more common in such diseases as :
 Cancer, especially pancreatic cancer
 Cardiac disease
 Parkinson’s disease
 Right sided strokes
 Multiple sclerosis
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Neurobiological and physical aspects of specific
diseases may contribute to depression
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BUT-differences in the prevalence of depression
across different diseases tend to disappear after
controlling for:
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Stage of disease
Severity of physical disability and distress
Location of treatment (inpatient vs outpatient)
Past personal and psychiatric history
Social support
 Cardiac Disease
▪ Increased disease progression and both cardiac and all-cause mortality
▪ Allosaimi & Baker 2012
▪ Van Melles et al 2004
 Diabetes
▪ Increased all-cause mortality
▪ Zhang et al 2005
▪ Katon et al 2005
▪ Lin et al 2009
 Cancer
▪
increased mortality in lung cancer
▪
▪
▪
▪
Nakaya, N et al 2008
Hamer, M et al 2009
Pinquart et al 2010
Temel et al 2012
 No
evidence that treatment of
depression with antidepressant
medication in cardiac patients reduces
mortality in patients with cardiac
disease, diabetes or cancer
 Mechanisms
that contribute to the
association of depression and
mortality are not clear
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Positive outcomes and
sustained improvement are
most likely to occur when
treatment is directed at
etiological and pathogenic
factors, rather than solely at
symptoms .
▪ Luytens et al, 2006
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Psychiatric interventions
should address subsystems of
variables that are relevant in
specific contexts
 Kendler et al 2008
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Systematic Reviews
 Psychotherapy as effective as
pharmacotherapy
▪ Williams and Dale, 2006
▪ Rodin et al , 2007
 Psychotherapy preferred to
pharmacotherapy with
advanced disease
▪ Akechi et, 2008
 Individual therapy may be
more effective than group
therapy (not specific to
cancer)
▪ Cuijpers, 2008
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Tailored psychological interventions
are the mainstay of treatment for all
patients
Pharmacotherapy should be reserved
for patients meeting criteria for
psychiatric disorders
 Outcomes are improved with
collaborative care
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Based on systematic review & meta-analysis
 No clinically important difference between
antidepressants and placebo in Rx of minor
depression.
 Shifting from drugs to psychological interventions
requires investment in human resources for training
and supervision and delivery of interventions
 In systems with no or low resources doctors should
still shift away from drug intervention for minor
depression as resources may be better spent
elsewhere in the health system.
.
Barbui et al Brit J Psychiatry 2011
Sertraline, citalopram, escitalopram are
relatively well-tolerated and have the fewest
drug-drug interactions
 Dual effects may be beneficial e.g.
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 Mirtazepine-weight gain
 Duloxetine-neuropathic pain relief
 Venlafaxine-hot flashes
▪ Li, Fitzgerald and Rodin JCO 2013
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Psychostimulants have not been shown to
relieve depression though they may have an
effect on fatigue
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Cognitive-behavioral approaches
 Relaxation therapy
 Biofeedback
 Guided imagery and hypnosis
 Cognitive Reframing
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Supportive-Expressive (psychodynamic) approaches
 emotional expression,
 self-understanding,
 psychological support
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:Progressive
physical disability
Complex treatment decisions
Disruption in self-concept
Fear of dependency
Crisis of meaning
Fear of death and dying
Pressure of time
Planning for the end
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Brief semi-structured
intervention
 3-6 individual sessions
 45-60 minutes in length
 Primary caregiver attends
one or more sessions
 Delivered over 6 months
 Semi-structured, with
attention to four domains
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Delivered by specially
trained mental health
professionals
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Ongoing weekly
supervision seminars
Symptom management
& communication with
healthcare providers
Changes in self &
relations with close others
Spirituality &
sense of meaning/purpose
Thinking of the future,
hope, and mortality
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This (CALM) has been the only
opportunity for us to be looked at as
people by the medical system. I think that
is really important because you are more
than the sum of your parts…
I have been able to grow as a person…it
makes me feel like I will be able to handle
death in a peaceful way.
▪ Nissim et al, Palliative Medicine 2011
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Phase II Study
 Significant reductions in symptoms of :
▪ Depression
▪ Distress about death and dying
 Significant improvement in spiritual
wellbeing
Lo… Rodin, Pall Med 2013
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Plato
428 -367 BCE
“The greatest mistake
physicians make is
that they attempt to
cure the body without
attempting to cure the
mind; yet the mind
and the body are one
and should not be
treated separately!”