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
