Distress Assessment & Management

Presented by: Barb Henry, APRN-BC, MSN

Bjzh@aol.com

Melvin S. Gale MD & Associates2135 Dana Ave, Suite 410

Cincinnati, Ohio 45207-1327 (513) 241-1811

http://www.galemd.com

Next CTC-ONS MeetingThursday, November 15th Good Samaritan Hospital

Conference Center at 6 p.m.

Topic: Stigma, Anxiety, Depression,

And Lung CancerPresented by: Lisa Maggio, RN,

PhDc, MSN, OCN, CTTS

www.cincinnati.vc.ons.org

Objective• Identify five components of distress assessment

and four interventions for distress management using the 2012 NCCN Guidelines.

Distress Thermometer & Problem List:

Practical problems

Family problems

Emotional problems

Physical problems

Spiritual / religious concerns

NCCN, 2012

Use Distress thermometer as you would the pain scale-0= no emotional distress, 10=severe emotional distress:

severe depression/suicidal thoughts/no support

Anyone who scores 4 or above on the Distress thermometer should be referred for psychiatric

assessment, counseling and/or medicationsLevine, 2012

Therapeutic Fly Fishing Retreats for Breast Cancer Survivors:Emotional Distress Outcomes

www.castingforrecovery.org

https://www.facebook.com/#!/CastingForRecoveryOhio?fref=ts

N=44 participants from 5 states

Henry & CFR, 2012

Ages of Participants

Henry & CFR, 2012

Years Since Diagnosis

Henry & CFR, 2012

Distress Thermometer Score Prior to the Retreat

Henry & CFR, 2012

Distress Thermometer Score Two Weeks Post-Retreat

Henry & CFR, 2012

1. Adler, N.E., & Page, A.E.K. (Eds). (2008). Cancer care for the whole patient: Meeting psychosocial health needs. Washington, DC: National Academies Press.

2. American Cancer Society (2012). Breast cancer facts and figures 2011-2012. Retrieved from: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-030975.pdf

3. Casting for Recovery. (n.d.) Retrieved from: http://www.castingforrecovery.org

4. NCCN. (n.d.) Distress guidelines. Retrieved from: http://www.nccn.org

Over 200,000 women are diagnosed each year with breast cancer (American Cancer Society, (ACS), 2012). Currently there are 2.5 million breast cancer survivors (ACS, 2012). Support groups lead to better outcomes in quality of life-physical, emotional and social well-being. 70% of women who participate in Casting For Recovery (CFR) programs do not attend other support groups (CFR, n.d.). CFR meets an important need. Many support groups are segregated by cancer “stage”. CFR includes Stage I through IV breast cancer survivors; in CFR-“any age, any stage” is the motto. CFR was founded by a fly fisher and a breast reconstructive surgeon in 1996 based on these principles: • The natural world is a healing force. • Cancer survivors can benefit from one weekend free of the stresses of medical treatment, workplace, & family concerns. • Participants experience the healing power of nature in an intimate, safe and nurturing structure. • Participants learn a fun new sport that promotes increased physical activity. CFR is a 501(c)3 non-profit organization that is endorsed by medical and psychosocial experts for its innovative healing program model.

• CFR offers free 2 ½ day retreats for 14 participants, the maximum numberrecommended for educational, psycho-social, and small group dynamics.

• Retreats are held in heated lodges that accommodate the participants incomfortable rooms. The scenic rural grounds include a pond or stream for flyfishing, hiking trails, comfortable meeting areas, dining and bathing facilities,and other amenities.

• CFR offers free 2 ½ day retreats for 14 participants, the maximum numberrecommended for educational, psycho-social, and small group dynamics.

• Retreats include food and lodging, roommate assignments, fly fishing instruction, gear fittings, lessons on fly tying and entomology, time for reflectionand bonding, one-on-one guided fishing, and facilitated small group counselingand medical education sessions.

• In 2011, 47 retreats in 33 states served over 650 survivors; by the end of 2011,CFR had served over 5,000 women since 1996 (CFR, n.d.)

Fly Fishing Retreats for Breast Cancer Survivors: Emotional Distress & Quality Of Life Outcomes

Barbara J. Henry, MSN, APRN-BCDNP Student, Northern Kentucky University, Highland Heights, KY

Melvin Gale, MD, & Associates

Methodology Findings

Introduction

References AcknowledgementsThe author would like to acknowledge the following for their help in making this research possible:

• Kate Fox, Lori Simon, & the administrative staff at Casting for Recovery

• Debbie Hampton, CFR Ohio Coordinator, volunteer staff and participants from the CFR program

• University of Cincinnati and Northern Kentucky University Doctorate of Nursing Practice Programs

• National Comprehensive Cancer Network

Clinical Implications

Demographics

Quality of life and distress data from this study is valuable in planning future cancer survivorship programs.

This study will be replicated with CFR participants in 2012 with the goal of obtaining information from a larger population from more states with a higher return rate.

Casting for Recovery is a valuable program to reduce and/or identify emotional distress and improve quality of lifein breast cancer survivors.

The NCCN Distress tool may be better understood if it were renamed the “Emotional Distress Tool” in order to help cancer survivors and staff understand what is meant by “Distress.”

Oncology nurses can use the Distress tool in clinical settings to provide cancer care for the whole person including psycho-social assessment, interventions, and referrals as recommended by the Institute of Medicine. (Adler & Page, 2008).

This was a pre- and post-test research design with 42 women from 5 states.

The study was approved by the University of Cincinnati Internal Review Board and determined to not cause any risk or harm to participants.

Letters of introduction to the study and distress tools with postage paid return envelopes were mailed to participants 2 weeks prior to the retreat.

70 tools were mailed with 47 returned by mail, 42 of the 47 completed pre-retreat tools and signed letters of consent returned, a 67% return rate.

Completed tools were assigned numbers and sent to the principal investigator without any identifiers in order to assure confidentiality of participants.

The principal investigator is a psychosocial facilitator for CFR but did not participate in any retreats held in 2011 when the data was gathered.

47 participants from five states participated in the survey: 7 from California, 10 from North Carolina, 10 from Ohio, 11 from South Carolina, and 9 from Texas. However 5 surveys had missing distress scores and were not tabulated in the final N=42

The mean age of participants was 55.2 years. The mean number of years since diagnosis was 5.02.

Note: Distress tool used with permission in the study on 3/21/2011 and in this poster from the NCCN on 9/4/2012.

15 of the 42 participants completed and returned the post-retreat distress tools for a return rate of 35%.

The mean pre-retreat distress score was 4.02. Distress scores above 4 indicate emotional distress in need of treatment and/or referral (National Comprehensive Cancer Network, n.d.)

The mean post-retreat distress score was 2.93, a significant decrease in emotional distress. This is even more significant given21 participants showed scores 4 or higher pre-retreat and only 3 participants had scores of 4 or higher post-retreat.

Problems were tabulated from both the pre- and post-retreat tools. The top 5 problems listed by participants were: 1) Worry, fears, and nervousness 2) Fatigue 3) Memory and concentration 4) Sadness and depression and 5) Sleep.

The 42 completed pre-retreat distress tools were collected at the nationalCFR office. Original data was shredded by the CFR study after the studywas completed.

The number circled by participants on the distress thermometer was considered the pre-test score.

Items checked by participants from the problem lists on the right side ofthe tool were also tabulated.

The 42 participants received another mailed distress tool to complete 2 weeks following the retreat with stamped return envelope.

Author Contact: Bjzh@aol.com

Prevalence of Mental Health Issues in People with Cancer

• _____ percent (or more) of all people diagnosed with cancer have significant psychosocial distress

• Less than 10% of these people actually are identified and referred for help.

• The suicide rate among cancer patients is ___ that among the general population.

NCCN, 2010

Interventions to Manage Emotional Distress

• Refer patients/caregivers to the Cancer Support Community (a.k.a. Wellness Community): http://www.cancersupportcommunity.org

• Refer patients/caregivers to Cancer Family Care http://www.cancerfamilycare.org

Interventions to Manage Emotional Distress

• Refer patients for spiritual/chaplain care as desired by the patient

• Provide education and support to patients & families, nurses are key! Use humor freely, listen, don’t give “pity” looks

• Talk to patients about other areas of their life, not just cancer; it’s about the person, not the disease

Common Psychiatric Medications Used in Oncology - Antidepressants

• SSRI’s- citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft)

• SNRI’s- desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor) , atomoxetine, (Strattera), vilazodone (ViiBRYD)

• Others- mirtazapine (Remeron), nefazedone (Serzone), trazodone (Oleptro), buproprion (Wellbutrin)

Epocratesonline.com, 2012

Common Psychiatric Medications Used in Oncology - Antidepressants

• Tricyclics- amitriptyline (Elavil), doxepin (Sinequan), nortriptyline (Pamelor), protriptylene (Vivactil), chlomipramine (Anafranil), imipramine (Tofranil), desipramine (Norpramin), trimipramine (Surmontil)

• MAOI’s- isocaboxazid (Marplan), phenezine (Nardil), seligiline (Emsam), tranylcypromine (Parnate)

Epocratesonline.com, 2012

Common Psychiatric Medications Used in Oncology: Anti-Anxiety Medications

Lorazepam (Ativan)

Clonazepam (Klonopin)

Alprazolam (Xanax)

Diazepam (Valium)

Oxazepam (Serax)

Chlordiazepoxide (Librium)

Buspirone (Buspar) (non-benzodiazepine anxiolytic)

Epocratesonline.com, 2012

Common Psychiatric Medications Used in Oncology: Anti-Anxiety Medications

Off label anxiety medications-

Propranolol (Inderal) (beta blocker)

Hydroxazine (Vistaril or Atarax)

Diphenhydramine (Benadryl)

Epocratesonline.com, 2012

Common Psychiatric Medications Used in Oncology: Sleep Aids

Zolpidem (Ambien)Flurazepam (Dalmane)Temazepam (Restoril)Triazolam (Halcion) Eszoplicone (Lunesta)Ramelteon (Rozeram)Zaleplon (Sonata)Estazolam (Prosom)Secobarbital (Seconal)Chloral Hydrate

Off label sleep agents: any of the medications from the anti-anxiety and antidepressant slides, as well as low dose antipsychotic medications

Epocratesonline.com, 2012

Less Common Psychiatric Medications Used in Oncology: Antipsychotics

Atypicals/2nd or 3rd Generation- aripiprazole (Abilify), asenopine (Saphris), clozapine (Clozaril), iloperidine (Fanapt), lurasidone (Latuda), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon)

Epocratesonline.com, 2012

Less Common Psychiatric Medications Used in Oncology: Antipsychotics

1st Generation- chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), loxapine (Loxitane), prochlorperazine (Compazine), thioridizine (Mellaril), thiothixene (Navane), trifluoperizine (Stelazine)

Epocratesonline.com, 2012

Less Common Psychiatric Medications Used in Oncology

• Mood Stabilizers/Bipolar Drugs

Valproic acid (Depakote), Carbemazepine (Tegretol), Lamotrigine (Lamictal), Lithium (Lithobid, Eskalith), Oxycarbemazepine (Trileptal), Gabapentin (Neurontin), Pregabalin (Lyrica)

Epocratesonline.com, 2012

Less Common Psychiatric Medications Used in Oncology

• Stimulants & ADHD Medications

Dextroamphetamine (Adderall, Dexadrine), Methylphenidate (Concerta, Desoxin, Ritalin, Metadate, Methylin), Methylphenidate transdermal (Daytrana), Dexmethylphenidate (Focalin), Guanfacine (Intuniv), Dexedrine (ProCentra), Lisdexamphetamine (Vyvanse), & Non-Stimulant s-Clonidine (Catapres, Kapvay), Atomoxine (Strattera)

Epocratesonline.com, 2012

Sexual Dysfunction Medications & Resources for Cancer Survivors

• Erectile Dysfunction Medications & DevicesTadalafil (Cialis), Vardenifil (Levitra), Sildenifil (Viagra), Yohimbine (Yocon), Alprostadil urethral-injection, transurethral, (Muse, Edex, Caverject)

• SSRI’s that MAY cause sexual side effectsCitalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft)

Resources:http://www.columbus.vc.ons.org/file_depot/0-10000000/0-10000/9206/folder/17505/2011%20Spring%20Conf%20Brixey.pdfLink to 2011 Molly Brixey presentation slides with more sexuality

info/websites

Epocratesonline.com, 2012

Sexual Dysfunction Medications

• Products of Vaginal DrynessWater based lubricants –KY jelly, Astroglide, Liquid Silk, ReplensHormones (unless ER+/PR+)-Vagifem (a vaginal pill to use daily x 2 weeks then twice/week), Estrogen creams, PremarinVaginal Dilators-for vaginal stenosis, use 3-4 times/weekKegal exercies to improve Kegal muscle strength

Brixey, 2011

Want to learn more about assessment and management of

psychosocial distress?

Integrating Psychosocial Care Into Practice Web Course - 8.5 CEUs: $69-ONS members; & $100-non ONS members

http://www.ons.org/CourseDetail.aspx?course_id=87

https://www.epocratesonline.com for psychiatric (and medical) medication photographs & patient education materials

Last but not least - don’t forget to manage your own distress!

My own Distress relief-ZUMBA!Join us for a FUN event to raise money for Mommy Has Breast

Cancer! All proceeds will go towards helping local women

undergoing breast cancer treatment.

Register online TODAY at www.MommyHasBreastCancer.org or get advance tickets from your Zumba instructor!

$10 Advance ticket. $15 At the door

Lakota Family YMCA6703 Yankee Rd, Middletown

45044(513) 779-3917