Magazine article Clinical Psychiatry News

Pharmacotherapy Is "Powerful Tool' in Palliative Care

Magazine article Clinical Psychiatry News

Pharmacotherapy Is "Powerful Tool' in Palliative Care

Article excerpt

When the American Board of Medical Specialties gives its first examination for subspecialty certification in Hospice and Palliative Medicine in 2008, it will be open to members of 10 specialties. Psychiatry will be among them.

This should be no surprise. Although palliative medicine has traditionally focused on alleviating pain and physical suffering and optimizing patients' quality of life, its scope has widened in recent years to address conventionally defined psychiatric syndromes as well as broader psychosocial and existential issues within the domain of psychiatry.

The prevalence of depression among terminally ill patients ranges from 20% to 50%, according to the Academy of Psychosomatic Medicine's Ad Hoc Committee on End-of-Life Care (J. Palliat. Med. 1998;1:113-5). Anxiety is less studied but apparently quite common, and "as many as 88% of patients develop delirium in the last several weeks of life," said Dr. William S. Breitbart, chief of the psychiatry service at Memorial Sloan-Kettering Cancer Center, New York.

In a particularly troubled subgroup--patients who wish for an early or hastened death--depression is strikingly common, said Dr. Harvey Max Chochinov, director of the Manitoba Palliative Care Research Unit at CancerCare Manitoba and professor of psychiatry at the University of Manitoba, Winnipeg.

His landmark study found that, among the 8.5% of 200 terminally ill patients in whom this wish was "serious and pervasive," the prevalence of depressive syndromes was 58.8%, compared with 7.7% among those who had no such desire (Am. J. Psychiatry 1995;152;8:1185-91).

But that study and others also have found that multiple factors including pain, lack of social support, and loss of a sense of dignity may be significant in this situation as well.

"Depression should be addressed, but not in isolation," Dr. Chochinov said. "There's usually far more going on ... a combination of physical, psychological, and existential issues. In addition to [being aware of] DSM-IV morbidities, psychiatrists need to be aware of this exquisitely painful and complex landscape, and to approach these issues with humility and open-mindedness."

Psychopharmacology, in particular, is "a powerful tool that needs to be applied judiciously and with skill, within this broader context," Dr. Chochinov said.

Generally, the use of psychotropics in palliative care should address the specific needs of this population. "My personal criteria revolve around function, rather than strict diagnostic criteria," said Dr. Max Henderson of the Institute of Psychiatry and St. Christopher's Hospice, London.

"I ask the patient what he would like to do but cannot--to see if depressive, anxiety, or other symptoms are impacting on his life," he said. An individual who wishes she could visit family or go out shopping may blame her inability to do so on advanced cancer, but it may actually be the result of low mood or anxiety, which would be responsive to treatment.

In the treatment of depression, "standard antidepressants have to be the cornerstone, as in the nonpalliative care population," Dr. Henderson said, but "one needs to pay even greater attention to the side effect profile." Sedation can be a particular difficulty since patients are frequently taking multiple medications, and one or more of these may themselves be sedating.

Although SSRIs are generally preferred, "the use of mirtazapine [Remeron] is increasing," he said. "It is well tolerated, has few drug-drug interactions, and causes less sedation at higher doses. …

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