what are the broad issues around mental health in advanced cancer? practical approaches to mental...
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What are the broad issues around mental health in
advanced cancer?
Practical approaches to mental health issues in palliative care
Practice Forum DoH 2012
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Outline 1
1. Mental health and mental ill-health
2. ‘normalisation’
3. The INDIVIDUAL and the cancer trajectory
4. Complexity
5. Depletion
6. ‘Diagnosis’ – need for a TRULY holistic framework
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Outline 2
8. Organizational contributions to distress
9. Mental health of staff
10. Challenging mental health issuesi. Underlying personality disorder
ii. Families (who carry their own history)
iii. Drug and alcohol issues
iv. Intellectual disability, autism
v. ‘serious’ mental illness• Schizophrenia, schizoaffective disorder,
bipolar affective disorderDr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Outline 3
11. Education and training
12. Translation of clinical research into practice
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Mental health and mental illness - 1
1. Preventative, preservative
Early intervention, facilitation of adjustment, enhancing coping style, communication skills, paced information, social supports
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Mental health and mental illness - 2
2. Reactive
(psychiatric morbidity consequent upon diagnosis, disease course, treatments)
– identification of high risk groups– screening– prompt treatment
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Mental health and mental illness - 3
3. Underlying psychiatric disorder (schizophrenia, schizoaffective disorder, bipolar affective disorder – but also OCD, eating disorders)
– access, collaborative care, adherence to treatment, perception of competence, social resources
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Anxiety
– ubiquitous
– strategies +/- medication
– extremely distressing
– treat like pain
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Depression
– >25%, increasing with advancing disease
– Under-recognized, under-rated, un-treated / under-treated
– Amplifies distressing symptoms (pain)– Different use of antidepressants in PC –
matching receptor profile with desired effect
– Psychostimulants – Research implications
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Post-trauma syndromes
• Arising from the experience of life-threatening disease or its treatment
• Reactivation of previous trauma in setting of dependence, helplessness, fear, threat to life
• Can emerge in delirium
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Delirium
• High prevalence
• Multifactorial
• Concept of ‘deliriant threshold’
• Life-threatening
• Highly distressing
• Nursing nightmare
• Hypoactive delirium missed
• Misdiagnosis Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Other organic mental states
• 1º cerebral tumour
• 2º cerebral metastases
• Leptomeningeal infiltration
• Limbic encephalitis
• Paraneoplastic syndromes
• Hepatic encephalopathy
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
‘Normalization’
Take care with using this counselling approach in a cancer setting;
may be experienced as out of touch, even patronizing
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
The individual and the cancer trajectory
What is the life story of the
person
who develops cancer?
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
“Risk”?
Symptoms
Investigations
Diagnosis
No Treatment
Death
SurgeryChemotherapyRadiotherapyStem cell transplant
Remission
Survival
RelapseChemotherapy
+/ - Radiotherapy
Death
Remission
Relapse
Palliative Care
Death
Death
Palliative care
Palliative care
“Risk”?
Symptoms
Investigations
Diagnosis
No Treatment
Death
SurgeryChemotherapyRadiotherapyStem cell transplant
Remission
Survival
RelapseChemotherapy
+/ - Radiotherapy
Death
Remission
Relapse
Palliative Care
Death
Death
Palliative care
Palliative care
age, developmental stage, IQ,
gender, sexuality, strengths,
vulnerabilities, personality,
attachments, losses, previous
trauma, social supports, culture,
religion, spiritual beliefs, past
psychiatric disorder, substance
use, comorbidities
UNIQUENESS
Complexity
• heterogeneity of cancer population in palliative care (cf spinal unit, cardiac unit) complex needs MDT
• RCTs difficult to mount ‘rational’ individual tailoring of treatments
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Depletion
• A product of prolonged stress and fear, toxic treatments, sub-optimal nutrition, reduced exercise or mobility, existential anguish, altered relationships to self and others, multiple losses……
• A useful concept when explaining that, just as the body is depleted and fatigued, so is the brain
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Diagnosis
• ‘knowing through’ – discerning, distinguishing – not limited to disease
• requires knowledge of patient’s underlying disease and treatment effects; past trauma, attachment style, losses, personality, coping strategies, psychiatric illness; social supports; IQ cultural influences; spiritual beliefs
• need to know context and time-frameDr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
“this patient won’t communicate
with us”
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
What is going on here?
• Angry• Depressed (especially agitated
depression)• Paranoid • Delirious (hyperactive)• Demented• Cerebral pathology
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
What’s going on here?• Depressed• Demoralized • Conservation-withdrawal• Given-up• Over-sedation• Delirium (hypoactive)• Sensory impairment (blind, deaf)• Unable to speak• Dying
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Organizational contributions to distress
• Delays
• Lack of continuity
• Poor communication
• Poor leadership
• Poor staff cohesion
• Lack of pathway co-ordination
• Unconscious acts that diminish dignity
• Random acts of kindnessDr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Staff health
• Compassion fatigue, burnout
• Dysfunctional teams – rampant splitting
• Reflective practice
• Supervision
• Self care
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Challenging mental health issues
• 1. Personality disorder– esp borderline, narcissistic, paranoid– traits may be accentuated where
dependency, attachment, trust issues paramount
– can create havoc in team functioning– early recognition and staff support
important
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Challenging mental health issues
• 2. Families– Dysfunctional, disengaged, enmeshed,
members with own agendas, members out of phase with the process,
– May have several personality disorders in one family!!
– Toll on staff– Caring for the family an extension of patient
care – ripple effect– Family caregiver guidelines
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Challenging mental health issues
• 3 Drug and alcohol issues– Perjorative attitudes– Alcohol and drug abuse often not
screened for– Tendency to withhold opiates for fear of
worsening addiction – but higher tolerance
– Fear of marketing drugs– Comorbid medical, social and forensic
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Challenging mental health issues
• 4. Intellectual disability and autism spectrum
– Therapeutic alliance– Communication of distress– Case-manager, secondary consultation,
in-service training
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Challenging mental health issues
• 5. Persistent serious mental illness– Bilateral ignorance of each other’s
principles and methods of care: PC/MH– Fear of death and dying (MH)– Discomfort with opiates (MH)– Fear of mental illness (PC)– Lack of skills in handling disturbed
patients (PC)– However many features in common
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Education and training
• Psychosocial skills in cancer care a specialist area
• The biological perspectives should always be considered
• Different disciplines, different roles need different skills training
• Professional development courses• Proposed degree courses• Statewide remit
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Translational research
• Designing studies that have clinical relevance
• Qualitative studies as well as quantitative studies
• The collaborative initiatives
• The VCCC
• Guidelines review and implementation
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital
Thank you!
Questions?
Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital