Palliative care has long recognized the importance of treating the whole person to address a patient's physical, mental, and spiritual suffering. To address psychological suffering, palliative care often draws upon the pharmacotherapy and psychotherapy offered by psychiatry. Several new developments have occurred in the past decade within psychiatry that impact palliative care. For example, the recent updating of the Diagnostic and Stastistical Manual of Mental Disorders has led to renewed discussions on how to best distinguish grief from depression or recognize that both may be present at the same time. In this article, we draw upon a team of psychiatric, palliative care, and dual-trained physicians to highlight the “Top 10” tips from psychiatry to provide relief for patients with chronic disease or at the end of life.
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References
1.
American Academy of Hospice and Palliative Medicine; Center to Advance Palliative Care, et al.: National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for quality palliative care, executive summary. J Palliat Med, 2004; 7:611–627.
2.
ColbyWH, DahlinC, LantosJ, et al.: The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines Domain 8: Ethical and legal aspects of care. HEC Forum, 2010; 22:117–131.
3.
DySM, KileyKB, AstK, et al.: Measuring what matters: Top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association. J Pain Symptom Manage, 2015; 49:773–781.
4.
OngCK, ForbesD: Embracing Cicely Saunders's concept of total pain. BMJ, 2005; 331:576.
5.
GanzelBL: Trauma-Informed Hospice and Palliative Care. Gerontologist, 2018; 58:409–419.
6.
BreitbartW, RosenfeldB, PessinH, et al.: Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA, 2000; 284:2907–2911.
7.
DowellD, HaegerichTM, ChouR: CDC Guideline for Prescribing Opioids for Chronic Pain?United States, 2016. JAMA, 2016; 315:1624–1622.
8.
PortenoyRK: Treatment of cancer pain. Lancet, 2011; 377:2236–2247.
9.
ScherrerJF, SalasJ, SullivanMD, et al.: Impact of adherence to antidepressants on long-term prescription opioid use cessation. Br J Psychiatry, 2018; 212:103–111.
10.
IsHakWW, CollisonK, DanovitchI, et al.: Screening for depression in hospitalized medical patients. J Hosp Med, 2017; 12:118–125.
11.
Diez-QuevedoC, RangilT, Sanchez-PlanellL, et al.: Validation and utility of the patient health questionnaire in diagnosing mental disorders in 1003 general hospital Spanish inpatients. Psychosom Med, 2001; 63:679–686.
12.
StrikJJ, HonigA, LousbergR, et al.: Sensitivity and specificity of observer and self-report questionnaires in major and minor depression following myocardial infarction. Psychosomatics, 2001; 42:423–428.
13.
AssarehAA, SharpleyCF, McFarlaneJR, et al.: Biological determinants of depression following bereavement. Neurosci Biobehav Rev, 2015; 49:171–181.
14.
SimonNM, ShearKM, ThompsonEH, et al.: The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Compr Psychiatry, 2007; 48:395–399.
15.
ZisookS, ReynoldsCF3rd, PiesR, et al.: Bereavement, complicated grief, and DSM, part 1: Depression. J Clin Psychiatry, 2010; 71:955–956.
16.
KristensenP, DyregrovK, DyregrovA: What distinguishes prolonged grief disorder from depression?. Tidsskr Nor Laegeforen, 2017; 137:538–539.
17.
WakefieldJC, FirstMB: Validity of the bereavement exclusion to major depression: Does the empirical evidence support the proposal to eliminate the exclusion in DSM-5?. World Psychiatry, 2012; 11:3–10.
18.
ShearMK: Complicated grief. N Engl J Med, 2015; 372:153–160.
19.
American Psychiatric A: Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Arlington, VA: American Psychiatric Pub, 2013.
20.
GelenbergAJ, FreemanMP, MarkowitzJC, et al.: Practice guideline for the treatment of patients with major depressive disorder third edition. Am J Psychiatry, 2010; 167:1.
21.
HollonSD, DeRubeisRJ, FawcettJ, et al.: Effect of cognitive therapy with antidepressant medications vs antidepressants alone on the rate of recovery in major depressive disorder: A randomized clinical trial. JAMA psychiatry, 2014; 71:1157–1164.
22.
HardySE: Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults. Am J Geriatr Pharmacother, 2009; 7:34–59.
23.
MalhiGS, ByrowY, BassettD, et al.: Stimulants for depression: On the up and up?. Aust N Z J Psychiatry, 2016; 50:203–207.
24.
MintonO, RichardsonA, SharpeM, et al.: Drug therapy for the management of cancer-related fatigue. Cochrane Database Syst Rev, 2010; 7:CD006704.
25.
CandyM, JonesL, WilliamsR, et al.: Psychostimulants for depression. Cochrane Database Syst Rev, 2008; 2: CD006722.
26.
Jean-PierreP, MorrowGR, RoscoeJA, et al.: A phase 3 randomized, placebo-controlled, double-blind, clinical trial of the effect of modafinil on cancer-related fatigue among 631 patients receiving chemotherapy. Cancer, 2010; 116:3513–3520.
27.
McIntyreRS, LeeY, ZhouAJ, et al.: The efficacy of psychostimulants in major depressive episodes: A systematic review and meta-analysis. J Clin Psychopharmacol, 2017; 37:412–418.
28.
VodermaierA, LucasS, LindenW, et al.: Anxiety after diagnosis predicts lung cancer-specific and overall survival in patients with stage III non-small cell lung cancer: A Population-Based Cohort Study. J Pain Symptom Manage, 2017; 53:1057–1065.
29.
BryantC, JacksonH, AmesD: The prevalence of anxiety in older adults: Methodological issues and a review of the literature. J Affect Disord, 2008; 109:233–250.
30.
ShiraiY, MiyashitaM, KawaM, et al.: Evaluation of care for leukemia and lymphoma patients during their last hospitalization from the perspective of the bereaved family. Leuk Res, 2016; 47:93–99.
31.
EkströmMP, Bornefalk-HermanssonA, AbernethyAP, et al.: Safety of benzodiazepines and opioids in very severe respiratory disease: National prospective study. BMJ, 2014; 348:g445.
32.
TamblynR, AbrahamowiczM, BergerRd, et al.: A 5-Year Prospective Assessment of the Risk Associated with Individual Benzodiazepines and Doses in New Elderly Users. J Am Geriatr Soc, 2005; 53:233–241.
33.
WangPS, BohnRL, GlynnRJ, et al.: Hazardous benzodiazepine regimens in the elderly: Effects of half-life, dosage, and duration on risk of hip fracture. Am J Psychiatry, 2001; 158:892–898.
34.
HosieA, DavidsonPM, AgarM, et al.: Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: A systematic review. Palliat Med, 2013; 27:486–498.
35.
FarrellKR, GanziniL: Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med, 1995; 155:2459–2464.
36.
WitloxJ, EurelingsLSM, de JongheJFM, et al.: Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: A meta-analysis. JAMA, 2010; 304:443–451.
37.
CasarettDJ, InouyeSK: Diagnosis and management of delirium near the end of life. Ann Intern Med, 2001; 135:32–40.
38.
MoritaT, TsunodaJ, InoueS, et al.: Survival Prediction of Terminally III Cancer Patients by Clinical Symptoms: Development of a Simple Indicator. Jpn J Clin Oncol, 1999; 29:156–159.
39.
PlonkWMJr, ArnoldRM: Terminal care: The last weeks of life. J Palliat Med, 2005; 8:1042–1054.
40.
BreitbartW, AliciY: Agitation and delirium at the end of life. JAMA, 2008; 300:2898–2910.
41.
MoyerDD: Terminal delirium in geriatric patients with cancer at end of life. Am J Hosp Palliat Med, 2011; 28:44–51.
42.
de la CruzM, RansingV, YennuS, et al.: The Frequency, Characteristics, and Outcomes Among Cancer Patients With Delirium Admitted to an Acute Palliative Care Unit. Oncologist, 2015; 20:1425–1431.
43.
ŞenelG, UysalN, OguzG, et al.: Delirium frequency and risk factors among patients with cancer in palliative care unit. Am J Hosp Palliat Med, 2017; 34:282–286.
44.
PandharipandePP, ElyEW: Humanizing the Treatment of Hyperactive Delirium in the Last Days of Life. JAMA, 2017; 318:1014–1015.
45.
HuiD, Frisbee-HumeS, WilsonA, et al.: Effect of lorazepam with haloperidol vs haloperidol alone on agitated delirium in patients with advanced cancer receiving palliative care: A randomized clinical trial. JAMA, 2017; 318:1047–1056.
46.
AgarMR, LawlorPG, QuinnS, et al.: Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial. JAMA Intern Med, 2017; 177:34–42.
47.
ShalevD, BrewsterK, ArbuckleMR, et al.: A staggered edge: End-of-life care in patients with severe mental illness. Gen Hosp Psychiatry, 2017; 44:1–3.
48.
MacleodAD: The reactivation of post-traumatic stress disorder in later life. Aust N Z J Psychiatry, 1994; 28:625–634.
49.
MotaN, TsaiJ, KirwinPD, et al.: Late-life exacerbation of PTSD symptoms in US veterans: Results from the National Health and Resilience in Veterans Study. J. Clin. Psychiatry, 2016; 77:348–354.
50.
SternTA, FricchioneGL, RosenbaumJF: Massachusetts General Hospital Handbook of General Hospital Psychiatry-E-Book. Philadelphia, PA: Elsevier Health Sciences, 2010.
51.
DaumitGL, PronovostPJ, AnthonyCB, et al.: Adverse events during medical and surgical hospitalizations for persons with schizophrenia. Arch Gen Psychiatry, 2006; 63:267–272.
52.
LawrenceD, HancockKJ, KiselyS: The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: Retrospective analysis of population based registers. BMJ, 2013; 346:f2539.
53.
WalkerER, McGeeRE, DrussBG: Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry, 2015; 72:334–341.
54.
OlfsonM, GerhardT, HuangC, et al.: Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry, 2015; 72:1172–1181.
55.
ElieD, MarinoA, Torres-PlatasSG, et al.: End-of-Life Care Preferences in Patients with Severe and Persistent Mental Illness and Chronic Medical Conditions: A Comparative Cross-Sectional Study. Am J Geriatr Psychiatry, 2018; 26:89–97.
56.
TrachselM, IrwinSA, Biller-AndornoN, et al.: Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry, 2016; 16:260.
57.
AppelbaumPS: Assessment of patients' competence to consent to treatment. N Engl J Med, 2007; 357:1834–1840.
58.
BoettgerS, BergmanM, JeneweinJ, et al.: Assessment of decisional capacity: Prevalence of medical illness and psychiatric comorbidities. Palliat Support Care, 2015; 13:1275–1281.
59.
SessumsLL, ZembrzuskaH, JacksonJL: Does this patient have medical decision-making capacity?. JAMA, 2011; 306:420–427.
60.
FernandezC, KennedyHG, KennedyM: The recovery of factors associated with decision-making capacity in individuals with psychosis. Br J Psychiatry Open, 2017; 3:113–119.
61.
LarkinA, HuttonP: Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis. Br J Psychiatry, 2017; 211:205–215.
62.
FangCK, ChangMC, ChenPJ, et al.: A correlational study of suicidal ideation with psychological distress, depression, and demoralization in patients with cancer. Support Care Cancer, 2014; 22:3165–3174.
63.
GriffithJL, GabyL: Brief psychotherapy at the bedside: Countering demoralization from medical illness. Psychosomatics, 2005; 46:109–116.
64.
KissaneDW, ClarkeDM, StreetAF: Demoralization syndrome—a relevant psychiatric diagnosis for palliative care. J Palliat Care, 2001; 17:12–21.
65.
KissaneDW: The contribution of demoralization to end of life decisionmaking. Hastings Cent Rep, 2004; 34:21–31.
66.
GriffithJL: Hope Modules: Brief psychotherapeutic interventions to counter demoralization from daily stressors of chronic illness. Acad Psychiatry, 2017; 29:458–411.
67.
HughesP, KerrI: Transference and countertransference in communication between doctor and patient. Adv Psychiatr Treat, 2000; 6:57–64.
68.
KoekkoekB, van MeijelB, HutschemaekersG: “Difficult patients” in mental health care: A review. Psychiatr Serv, 2006; 57:795–802.
69.
BostonPH, MountBM: The caregiver's perspective on existential and spiritual distress in palliative care. J Pain Symptom Manage, 2006; 32:13–26.
70.
KatzRS, JohnsonTA: When Professionals Weep: Emotional and Countertransference Responses in Palliative and End-of-Life Care. New York, NY: Routledge, 2016.
71.
StiefelF, NakamuraK, TeruiT, et al.: Collusions Between Patients and Clinicians in End-of-Life Care: Why Clarity Matters. J Pain Symptom Manage, 2017; 53:776–782.
MercadanteS, AielliF, AdileC, et al.: Sleep disturbances in patients with advanced cancer in different palliative care settings. J Pain Symptom Manage, 2015; 50:786–792.
74.
MercadanteS, AdileC, FerreraP, et al.: Sleep disturbances in advanced cancer patients admitted to a supportive/palliative care unit. Support Care Cancer, 2017; 25:1301–1306.
75.
EdwardsRR, AlmeidaDM, KlickB, et al.: Duration of sleep contributes to next-day pain report in the general population. Pain, 2008; 137:202–207.
76.
O'BrienEM, WaxenbergLB, AtchisonJW, et al.: Negative mood mediates the effect of poor sleep on pain among chronic pain patients. Clin J Pain, 2010; 26:310–319.
77.
OkifujiA, HareBD: Do sleep disorders contribute to pain sensitivity?. Curr Rheumatol Rep, 2011; 13:528–534.
78.
Delgado-GuayM, YennurajalingamS, ParsonsH, et al.: Association between self-reported sleep disturbance and other symptoms in patients with advanced cancer. J Pain Symptom Manage, 2011; 41:819–827.
79.
VitielloMV, McCurrySM, ShortreedSM, et al.: Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia. Pain, 2014; 155:1547–1554.
80.
MorinCM, BootzinRR, BuysseDJ: Psychological and Behavioral Treatment of Insomnia: Update of the Recent Evidence (1998–2004). Sleep, 2006; 29:1398–1414.
81.
MorgenthalerT, KramerM, AlessiC, et al.: Practice parameters for the psychological and behavioral treatment of insomnia: An update. An american academy of sleep medicine report. Sleep, 2006; 29:1415–1419.
82.
HultcrantzM, SvenssonT, DerolfÅR, et al.: Incidence and risk factors for suicide and attempted suicide following a diagnosis of hematological malignancy. Cancer Med, 2015; 4:147–154.
83.
MisonoS, WeissNS, FannJR, et al.: Incidence of suicide in persons with cancer. JCO, 2008; 26:4731–4738.
84.
JuurlinkDN, HerrmannN, SzalaiJP, et al.: Medical illness and the risk of suicide in the elderly. Arch Intern Med, 2004; 164:1179–1184.
85.
GoodwinRD, MarusicA, HovenCW: Suicide attempts in the United States: The role of physical illness. Soc Sci Med, 2003; 56:1783–1788.
86.
KanzlerKE, BryanCJ, McGearyDD, et al.: Suicidal ideation and perceived burdensomeness in patients with chronic pain. Pain Pract, 2012; 12:602–609.
87.
JoinerTEJr, PettitJW, WalkerRL: Perceived burdensomeness and suicidality: Two studies on the suicide notes of those attempting and those completing suicide. J Soc Clin Psychol, 2002; 21:531–545.
88.
DazziT, GribbleR, WesselyS, et al.: Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?. Psychol Med, 2014; 44:3361–3363.
89.
DeCouCR, SchumannME: On the Iatrogenic Risk of Assessing Suicidality: A Meta-Analysis. Suicide Life Threat Behav, 2017 [Epub ahead of print]; DOI: 10.1111/sltb.12368.
90.
Rodríguez-PratA, BalaguerA, BoothA, et al.: Understanding patients' experiences of the wish to hasten death: An updated and expanded systematic review and meta-ethnography. BMJ Open, 2017; 7:e016659.
