A HARDER PAIN TO BEAR

DEARBHAIL LEWIS

CONSULTANT PSYCHIATRIST

LIAISON PSYCHIATRY SERVICE (OVER 65S)

BELFAST HEALTH AND SOCIAL CARE TRUST

APM TRAINEE COMMITTEE

APM SUPPORTIVE AND PALLIATIVE CARE CONFERENCE

30/3/17

‘Mental pain is less

dramatic than

physical pain, but

it is more common

and also more

hard to bear.’

CS

Lewis

OVERVIEW

• What is anxiety?

• Detection in the palliative care setting

• Management

• What is depression?

• Detection in the palliative care setting

• Management

‘Our anxiety does not empty tomorrow of its sorrows, but only empties today of its strengths.’

Charles Haddon Spurgeon Preacher

The Scream – Edvard

Munch

PANIC DISORDER F41.0

• Recurrent attacks of severe anxiety

• Unpredictable

• Discrete episode of intense fear

• Starts abruptly

• Dizzy, lightheaded

• Derealization/depersonalization

• Fear of losing control

• Fear of dying

PANIC DISORDER F41.0

AUTONOMIC AROUSAL

SYMPTOMS

• Palpitations

• Sweating

• Trembling

• Dry mouth

CHEST/ABDOMEN

• Difficulty breathing

• Feeling of choking

• Chest pain/discomfort

• Nausea

General symptoms

Hot flushes/cold chills

Numbness/tingling sensations

GENERALIZED ANXIETY DISORDER F41.1

• Autonomic arousal

• Palpitations

• Sweating

• Trembling

• Dry mouth

• Symptoms chest/abdomen

• Difficulty breathing

• Feeling of choking

• Chest pain/discomfort

• Nausea/abdominal distress

6/12 – tension, worry, apprehension

GENERALIZED ANXIETY DISORDER F41.1

• General Symptoms

• Hot flushes/cold chills

• Numbness/tingling

• Muscle tension/aches

• Restlessness/inability to

relax

• Feeling ‘on edge’

• Difficulty swallowing

• Non-specific symptoms

• Exaggerated startle

• Difficulty concentrating

• Irritability

• Initial insomnia

GENERALIZED ANXIETY DISORDER F41.1

• Symptoms involving the Mental State

• Dizzy/light-headed

• Derealization/depersonalization

• Fear of losing control

• Fear of dying

• Not due to a physical disorder

ANXIETY IN PALLIATIVE CARE SETTING

• Foreboding, anxiety and dread intensify when death

imminent

• Insomnia, less restorative sleep, nightmares

• Recurrent thoughts re cancer, dependency, death

• Uncontrolled pain

• Change in physical state

• Medications

• Withdrawal states

ANXIETY IN PALLIATIVE CARE SETTING

• Persistent anxiety related to chemotherapy

• Distress/disability

• Medical morbidity

• Marker of depression

NICE GUIDANCETREATMENT FOR ANXIETY

• ‘Stepped care’

• Comprehensive assessment

• Treat primary disorder first

• Psychological therapy first line

• SSRIs (Sertraline) first line pharmacotherapy

• Verbal/written information - benefits/disadvantages

• Combination therapy if complex

NICE GUIDANCETREATMENT FOR ANXIETY

• Panic disorder

• BDZs should not be used

• SSRI first line

• Self help

• GAD

• BDZs should not be used beyond 2-4/52

• SSRI first line

• SNRI/Pregabalin

• Psychological intervention

Depression is the most unpleasantthing I have ever experienced. It isthat absence of being able toenvisage that you will ever becheerful again. The absence of hope.That very deadened feeling, which isso very different from feeling sad.Sad hurts, but it’s a healthy feeling.It is a necessary thing to feel.Depression is very different.

JK Rowling

DEPRESSIVE EPISODE F32

• Duration at least 2/52

• Depressed mood - most of the day, almost every day

• Reduced self esteem & self confidence

• Ideas of guilt

• Ideas of worthlessness

• Decreased energy

• Recurrent thoughts of death/suicide

• Poor concentration

• Not due to psychoactive substance use/organic disorder

DEPRESSIVE EPISODE F32

• Somatic symptoms

• Loss of interest/pleasure

• Lack of emotional reactions

• EMW

• DMV

• Psychomotor retardation/agitation

• Loss of appetite

• Weight loss

• Loss of libido

SEVERITY

• Mild F32.0

• Moderate F32.1

• Severe (without psychotic symptoms) F32.2

• Severe with psychotic symptoms F32.3

• Delusions/hallucinations

• Depressive

• Guilty

• Hypochondriacal

• Nihilistic

• Self referential

• Persecutory

• Depressive stupor

DEPRESSION IN THE PALLIATIVE SETTING

• Biological features

• Adjustment disorder

• Minimise disability/pain

• Progression of disease

• Enable psychosocial support

• Primary versus secondary

• Physical causes

• Medication

• Alcohol

• Time limited for response to treatment

Holtom and

Barraclough

Palliative Medicine

2000

• Use of HADS

associated with

increased

antidepressant

prescription

• Acceptable to

patients

• Facilitate

discussion

RISK FACTORS

• Age – younger patients

• Prior episode of depression

• Lack of adequate social and psychological support

• Decreasing functional status

• Increased pain

• Illness related factors

• Existential concerns

NICE GUIDANCE TREATMENT FOR DEPRESSION

• Antidepressants not first line mild depression

• Monitoring, guided self help, CBT, exercise

• Moderate-severe

• SSRI

• Inform re discontinuation effects

• Treatment resistant

• Augmentation

• ECT – severe and treatment resistant

Photo Credit – University of

Michigan

CONSIDERATION OF MEDS

• SSRIs

• N&V, diarrhoea, agitation, headache, insomnia, bleeding

• Citalopram/Escitalopram

• QTc prolongation, T½ 30-33 hours, drops/liquid, fewer active

metabolites

• Fluoxetine

• Insomnia, agitation, T½ 4-6/7, liquid

• Paroxetine

• Discontinuation symptoms

• Sertraline

• T½ 26 hrs, tablets only, fewer active metabolites

CONSIDERATION OF MEDS

• TCAs

• Sedation, postural hypotension, tachycardia, arrhythmia,

dry mouth, blurred vision, constipation, urinary retention

• Liquid – amitrityline, lofepramine

• MAOI

• Specialist advice

• Agomelatine

• Tablets only, hepatitic LFTS, nausea, insomnia, T½ 1-2 hrs

CONSIDERATION OF MEDS

• Duloxetine

• Tablets only, nausea, dry mouth, anorexia, constipation,

somnolence T½ 12 hrs

• Mirtazapine

• ↑appetite, sedation, vomiting, postural hypotension,

tachycardia, orodispersible prep

• Venlafaxine

• Nausea, insomnia, somnolence, headache,

constipation, tablets only

‘Never say 'pull yourself together' or 'cheer up' unless you're also going to provide detailed, foolproof instructions.’

Matt Haig Reasons to Stay Alive

‘You may not control life's circumstances, but getting to be the author of your life means getting to control what you do with them.’

Atul Gawande Being Mortal; Medicine and What Matters in the End

REFERENCES

• http://fac.ksu.edu.sa/sites/default/files/Prescribing_Guidelines11.pdf

Maudsley Prescribing Guidelines

• ICD-10 World Health Organisation, Churchill Livingstone

• Geriatric Consultation Liaison Psychiatry Melding & Draper Oxford

University Press, 2007

• Liaison psychiatry in palliative care Barraclough Cahpter in Liaison

Psychiatry: Planning Services for Specialist Settings Peveler, Feldman

and Friedman, Gaskell, 2000

• Psychosomatic Medicine Amos and Robinson Cambridge University

Press, 2010

• ABC of palliative care Depression, anxiety, and confusion

Barraclough in BMJ 1997; 315;1365-1368

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127856/pdf/940278

2.pdf

REFERENCES

• Is the Hospital Anxiety and Depression Scale (HADS) useful in

assessing depression in palliative care? Holtom & Barraclough in

Palliative Medicine 2000; 14: 219–220

• Handbook of Psychiatry in Palliative Medicine Chochinov & Breitbart

Oxford 2009

• The Psychiatry of Palliative Medicine Macleod Radcliffe 2011

• Prevalence of depression, anxiety, and adjustment disorder in

oncological, haematological, and palliative-care settings: a meta-

analysis of 94 interview-based studies Mitchell in The Lancet

Oncology 2011;12 (2);160–174

• Antidepressants for the treatment of depression in palliative care:

systematic review and meta-analysis Rayner et al in Palliative

Medicine 2011; 25 (1); 36-51