Current Psychiatry

Persons addicted to drugs often are among the most marginalized psychiatric patients, but are in need of the most support.¹ Many of these patients have comorbid medical and psychiatric problems, including difficult-to-treat pathologies that may have developed because of a traumatic experience or an attachment disorder that dominates their emotional lives.² These patients value clinicians who engage them in an open, nonjudgmental, and empathetic way.

Eliciting a patient’s reasons for change and introducing him (her) to a variety of peer-led recovery group options that complement and support psychotherapy and pharmacotherapy can be valuable. Although most clinicians are aware of the traditional 12-step group model that embraces spirituality, many might know less about other groups that can play an instrumental role in engaging patients and placing them on the path to recovery.

Click here for another Pearl on familiarizing yourself with Alcoholics Anonymous dictums.

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Persons addicted to drugs often are among the most marginalized psychiatric patients, but are in need of the most support.¹ Many of these patients have comorbid medical and psychiatric problems, including difficult-to-treat pathologies that may have developed because of a traumatic experience or an attachment disorder that dominates their emotional lives.² These patients value clinicians who engage them in an open, nonjudgmental, and empathetic way.

Eliciting a patient’s reasons for change and introducing him (her) to a variety of peer-led recovery group options that complement and support psychotherapy and pharmacotherapy can be valuable. Although most clinicians are aware of the traditional 12-step group model that embraces spirituality, many might know less about other groups that can play an instrumental role in engaging patients and placing them on the path to recovery.

Click here for another Pearl on familiarizing yourself with Alcoholics Anonymous dictums.

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Persons addicted to drugs often are among the most marginalized psychiatric patients, but are in need of the most support.¹ Many of these patients have comorbid medical and psychiatric problems, including difficult-to-treat pathologies that may have developed because of a traumatic experience or an attachment disorder that dominates their emotional lives.² These patients value clinicians who engage them in an open, nonjudgmental, and empathetic way.

Eliciting a patient’s reasons for change and introducing him (her) to a variety of peer-led recovery group options that complement and support psychotherapy and pharmacotherapy can be valuable. Although most clinicians are aware of the traditional 12-step group model that embraces spirituality, many might know less about other groups that can play an instrumental role in engaging patients and placing them on the path to recovery.

Click here for another Pearl on familiarizing yourself with Alcoholics Anonymous dictums.

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Concerns about prescription medication abuse have led to the creation of remediation plans directed to reduce overuse, multiple prescribers, and diversion of prescribed drugs. One such plan from the United Kingdom, described below, has shown it is possible to taper a patient off of benzodiazepines.^1,2

Before starting a tapering plan, inform the patient about the risks of withdrawal.³ Abrupt reductions from high-dose benzodiazepines can result in seizures, psychotic reactions, and agitation.^1-3 Understanding the tapering regimen enhances compliance and outcomes. Stress the importance of careful adherence and provide close psychosocial monitoring and fail-safe means for patient contact if someone is experiencing difficulties. Supportive psychotherapy improves the prognosis.⁴ On a clinical basis, additional, adjunctive, symptomatic, or other medications may be required for safe illness management.

Managing comorbid medical conditions and psychopathologies—including addressing other substances of abuse—is important.^1-4 Tapering one or more substances at a time—even nicotine—is not advised. Refer patients to a self-help group or substance abuse rehabilitation program.

Slow tapering is safer and better tolerated than more abrupt techniques.^1-5 If the patient experiences overt clinical signs of withdrawal, such as tachycardia or other hyperadrenergia during dosage reduction, maintain the previous dosage until the next tapering date.

For persons who take a short-acting benzodiazepine—eg, alprazolam or lorazepam—convert the dosage into an equivalent dosage of a long-acting benzodiazepine—eg, diazepam.^1,2 Metabolized slowly, with a long half-life, diazepam allows a consistent, slow decline in concentration while tapering the dosage. This helps avoid severe withdrawal.^1-5 For patients who have been taking alprazolam or clonazepam, 1 mg, the equivalent diazepam dosage would be 20 mg; for temazepam, 30 mg, the diazepam dosage would be 15 mg; for lorazepam, 1 mg, oxazepam, 20 mg, or chlordiazepoxide, 25 mg, the diazepam dosage would be 10 mg.^1,2

Prescribe the to-be-tapered benzodiazepine at five-sixths of that dose and prescribe one-sixth of the diazepam amount daily. Proceed with tapering
every 1 to 2 weeks by a one-sixth dose reduction of the tapered medication and a one-sixth increase in diazepam. Continue until diazepam is used alone and well-tolerated.

Once the patient is taking only diazepam, decrease the dosage by 2 mg every 2 weeks until the patient is doing well on a relatively small dosage of diazepam.^1,2 Subsequent diazepam reductions are at 1 mg less every 1 to 2 weeks, until the patient is able to completely discontinue the medication.

Continue monitoring until clinical stability is achieved or otherwise indicated. Be aware that some people might switch to other substances of abuse.

Concerns about prescription medication abuse have led to the creation of remediation plans directed to reduce overuse, multiple prescribers, and diversion of prescribed drugs. One such plan from the United Kingdom, described below, has shown it is possible to taper a patient off of benzodiazepines.^1,2

Before starting a tapering plan, inform the patient about the risks of withdrawal.³ Abrupt reductions from high-dose benzodiazepines can result in seizures, psychotic reactions, and agitation.^1-3 Understanding the tapering regimen enhances compliance and outcomes. Stress the importance of careful adherence and provide close psychosocial monitoring and fail-safe means for patient contact if someone is experiencing difficulties. Supportive psychotherapy improves the prognosis.⁴ On a clinical basis, additional, adjunctive, symptomatic, or other medications may be required for safe illness management.

Managing comorbid medical conditions and psychopathologies—including addressing other substances of abuse—is important.^1-4 Tapering one or more substances at a time—even nicotine—is not advised. Refer patients to a self-help group or substance abuse rehabilitation program.

Slow tapering is safer and better tolerated than more abrupt techniques.^1-5 If the patient experiences overt clinical signs of withdrawal, such as tachycardia or other hyperadrenergia during dosage reduction, maintain the previous dosage until the next tapering date.

For persons who take a short-acting benzodiazepine—eg, alprazolam or lorazepam—convert the dosage into an equivalent dosage of a long-acting benzodiazepine—eg, diazepam.^1,2 Metabolized slowly, with a long half-life, diazepam allows a consistent, slow decline in concentration while tapering the dosage. This helps avoid severe withdrawal.^1-5 For patients who have been taking alprazolam or clonazepam, 1 mg, the equivalent diazepam dosage would be 20 mg; for temazepam, 30 mg, the diazepam dosage would be 15 mg; for lorazepam, 1 mg, oxazepam, 20 mg, or chlordiazepoxide, 25 mg, the diazepam dosage would be 10 mg.^1,2

Prescribe the to-be-tapered benzodiazepine at five-sixths of that dose and prescribe one-sixth of the diazepam amount daily. Proceed with tapering
every 1 to 2 weeks by a one-sixth dose reduction of the tapered medication and a one-sixth increase in diazepam. Continue until diazepam is used alone and well-tolerated.

Once the patient is taking only diazepam, decrease the dosage by 2 mg every 2 weeks until the patient is doing well on a relatively small dosage of diazepam.^1,2 Subsequent diazepam reductions are at 1 mg less every 1 to 2 weeks, until the patient is able to completely discontinue the medication.

Continue monitoring until clinical stability is achieved or otherwise indicated. Be aware that some people might switch to other substances of abuse.

Concerns about prescription medication abuse have led to the creation of remediation plans directed to reduce overuse, multiple prescribers, and diversion of prescribed drugs. One such plan from the United Kingdom, described below, has shown it is possible to taper a patient off of benzodiazepines.^1,2

Before starting a tapering plan, inform the patient about the risks of withdrawal.³ Abrupt reductions from high-dose benzodiazepines can result in seizures, psychotic reactions, and agitation.^1-3 Understanding the tapering regimen enhances compliance and outcomes. Stress the importance of careful adherence and provide close psychosocial monitoring and fail-safe means for patient contact if someone is experiencing difficulties. Supportive psychotherapy improves the prognosis.⁴ On a clinical basis, additional, adjunctive, symptomatic, or other medications may be required for safe illness management.

Managing comorbid medical conditions and psychopathologies—including addressing other substances of abuse—is important.^1-4 Tapering one or more substances at a time—even nicotine—is not advised. Refer patients to a self-help group or substance abuse rehabilitation program.

Slow tapering is safer and better tolerated than more abrupt techniques.^1-5 If the patient experiences overt clinical signs of withdrawal, such as tachycardia or other hyperadrenergia during dosage reduction, maintain the previous dosage until the next tapering date.

For persons who take a short-acting benzodiazepine—eg, alprazolam or lorazepam—convert the dosage into an equivalent dosage of a long-acting benzodiazepine—eg, diazepam.^1,2 Metabolized slowly, with a long half-life, diazepam allows a consistent, slow decline in concentration while tapering the dosage. This helps avoid severe withdrawal.^1-5 For patients who have been taking alprazolam or clonazepam, 1 mg, the equivalent diazepam dosage would be 20 mg; for temazepam, 30 mg, the diazepam dosage would be 15 mg; for lorazepam, 1 mg, oxazepam, 20 mg, or chlordiazepoxide, 25 mg, the diazepam dosage would be 10 mg.^1,2

Prescribe the to-be-tapered benzodiazepine at five-sixths of that dose and prescribe one-sixth of the diazepam amount daily. Proceed with tapering
every 1 to 2 weeks by a one-sixth dose reduction of the tapered medication and a one-sixth increase in diazepam. Continue until diazepam is used alone and well-tolerated.

Once the patient is taking only diazepam, decrease the dosage by 2 mg every 2 weeks until the patient is doing well on a relatively small dosage of diazepam.^1,2 Subsequent diazepam reductions are at 1 mg less every 1 to 2 weeks, until the patient is able to completely discontinue the medication.

Continue monitoring until clinical stability is achieved or otherwise indicated. Be aware that some people might switch to other substances of abuse.

Providing patients and their families with information and education about their psychiatric illness is a central tenet of mental health care. Discussions about diagnostic impressions, treatment options, and the risks and benefits of interventions are customary. Additionally, patients and families often receive written material or referral to other information sources, including self-help books and a growing number of online resources. Although patient education remains a useful and expected element of good care, there is evidence that, alone, it is insufficient to change health behaviors.¹

A growing body of literature and clinical experience suggests that self-management strategies complement patient education and improve treatment outcomes for patients with chronic illnesses, including psychiatric conditions.^2,3 The Cochrane Collaboration describes patient education as “teaching or training of patients concerning their own health needs,” and self-management as “the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a long-term disorder.”⁴

In this article, we review:

Principles of self-management

Chronic care models must account for conditions in which the clinical course can be variable, that are not amenable to a cure, and that demand long-term treatment. Optimal health outcomes rely on patients accurately monitoring, reporting, and responding to their symptoms, while engaging in critical health-related behaviors. In addition, clinicians must teach, partner with, and motivate patients to engage in crucial disease-management activities. Although typically not considered in this light, we believe most psychiatric disorders are best approached through a long-term care model, and benefit from self-management principles.

Basics of self-management include:

Corbin and Strauss believe effective “self-managers” achieve competency in three areas:

Proficiency in these three “self-manager” domains is enhanced by mastering five key self-management skills outlined in Table 1.⁷

Successful intervention programs vary widely with regard to individual vs group formats, communication interface, and involved health professionals. However, evidence indicates that problem solving, decision making, and action planning are key components.⁷ Successful planning includes:

Table 2 illustrates elements of successful action plans in our Action Planning Worksheet. Adapted from the work of Scharzer,⁸ Prochaska,⁹ and Clark,¹⁰ we developed this self-management tool for individual and group treatment settings. It serves as a vehicle for collaborative patient-provider discussion and planning. The nuts-and-bolts nature of the discussions inevitably leads to learning new, important, and often unexpected information about our patients’ daily lives and the challenges they face as they share their dominant priorities, fears, and insecurities.

Patients provide consistently positive feedback about action planning, and clinicians often find that the process reveals fruitful areas for further psychotherapeutic intervention. Examples include identifying a range of negative automatic thoughts or catastrophic thinking impeding initiation of important activation, and exposure activities for depressed or anxious patients.

Knowing what to do is different than actually doing it. Changing behavior is difficult in the best circumstances, let alone with the strain of a chronic illness. It is critical to recognize that the presence of depressive symptoms significantly reduces the likelihood that patients will employ self-management practices.¹¹ When combined with anxiety and the impairment of motivation and executive functioning that is common in psychiatric conditions, it is not surprising that patients with a mental health condition struggle to embrace ownership of their illness and engage in critical health behaviors—which may include adhering to medication regimens; maintaining a healthy sleep cycle, nutrition, and exercise routines; vigilant symptom surveillance; and carrying out an agreed-upon action plan.

Interventions

Professionally-guided “light-touch” interventions and technology-assisted self-management interventions also can improve patient engagement in activities through individual encounters, group forums, and technology-mediated exchanges, including telephone, email, text message, tele-health, and web-based interventions.¹³ The DE-STRESS (Delivery of Self Training and Education for Stressful Situations) model illustrates these principles. This 8-week program combines elements of face-to-face, email, telephone, and web-based assignments and exchanges, and demonstrates a decline in posttraumatic stress disorder, depression, and anxiety scores.¹⁴ Our Michigan Depression Outreach and Collaborative Care program is another example of a self-management intervention (Box 1).

Helping patients understand when common symptoms such as impaired concentration or dizziness should be “watched”—rather than responded to aggressively—is crucial for effective long-term management.

Challenges

Health care delivery and medical educational models have been slow to embrace this change to long-term care models because doing so involves what might be uncomfortable shifts in roles and responsibilities. Effective care for long-term illness necessitates that the patient become an expert on his (her) illness, and be an active participant and partner in their treatment. Preparing health professionals for this new role as teacher, mentor, and collaborator presents a challenge to health care systems and educational programs across disciplines.

When trying to facilitate effective patient-provider partnerships, it is important to recognize the variability in patient preference for what and how information is shared, how decisions are made, and the role patients are asked to play in their care. Patients differ in their desire for an active or collaborative shared-decision model; some prefer more directive provider communication and a passive role.¹⁸ Preferences are influenced by variables such as age, sex, race, anxiety level, and education.¹⁹ Open discussion of these matters between caregivers and patients is important; studies have shown that failure to address these issues of “fit” can
impede communication, healthy behavior, and positive outcomes.

Bottom Line

Emerging care models demand that health care providers become teachers and motivators to help patients develop and implement patterns of health surveillance and intervention that will optimize their well-being and functionality. As active collaborators in their care, patients form a partnership with their care teams, allowing for regular, reciprocal exchange of information and shared decision-making. This shift to a partnership creates new, exciting roles and responsibilities for all parties.

Related Resources

• Improving Chronic Illness Care. www.improvingchroniccare.org.
• Chronic disease self-management program (Better Choices, Better Health workshop). Stanford School of Medicine. http://patienteducation.stanford.edu/programs/cdsmp.html.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Featured Audio
Thomas E. Fluent, MD, talks about addressing patient resistance to a self-management model of care. Dr. Fluent is Clinical Assistant Professor, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.

Providing patients and their families with information and education about their psychiatric illness is a central tenet of mental health care. Discussions about diagnostic impressions, treatment options, and the risks and benefits of interventions are customary. Additionally, patients and families often receive written material or referral to other information sources, including self-help books and a growing number of online resources. Although patient education remains a useful and expected element of good care, there is evidence that, alone, it is insufficient to change health behaviors.¹

A growing body of literature and clinical experience suggests that self-management strategies complement patient education and improve treatment outcomes for patients with chronic illnesses, including psychiatric conditions.^2,3 The Cochrane Collaboration describes patient education as “teaching or training of patients concerning their own health needs,” and self-management as “the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a long-term disorder.”⁴

In this article, we review:

Principles of self-management

Chronic care models must account for conditions in which the clinical course can be variable, that are not amenable to a cure, and that demand long-term treatment. Optimal health outcomes rely on patients accurately monitoring, reporting, and responding to their symptoms, while engaging in critical health-related behaviors. In addition, clinicians must teach, partner with, and motivate patients to engage in crucial disease-management activities. Although typically not considered in this light, we believe most psychiatric disorders are best approached through a long-term care model, and benefit from self-management principles.

Basics of self-management include:

Corbin and Strauss believe effective “self-managers” achieve competency in three areas:

Proficiency in these three “self-manager” domains is enhanced by mastering five key self-management skills outlined in Table 1.⁷

Successful intervention programs vary widely with regard to individual vs group formats, communication interface, and involved health professionals. However, evidence indicates that problem solving, decision making, and action planning are key components.⁷ Successful planning includes:

Table 2 illustrates elements of successful action plans in our Action Planning Worksheet. Adapted from the work of Scharzer,⁸ Prochaska,⁹ and Clark,¹⁰ we developed this self-management tool for individual and group treatment settings. It serves as a vehicle for collaborative patient-provider discussion and planning. The nuts-and-bolts nature of the discussions inevitably leads to learning new, important, and often unexpected information about our patients’ daily lives and the challenges they face as they share their dominant priorities, fears, and insecurities.

Patients provide consistently positive feedback about action planning, and clinicians often find that the process reveals fruitful areas for further psychotherapeutic intervention. Examples include identifying a range of negative automatic thoughts or catastrophic thinking impeding initiation of important activation, and exposure activities for depressed or anxious patients.

Knowing what to do is different than actually doing it. Changing behavior is difficult in the best circumstances, let alone with the strain of a chronic illness. It is critical to recognize that the presence of depressive symptoms significantly reduces the likelihood that patients will employ self-management practices.¹¹ When combined with anxiety and the impairment of motivation and executive functioning that is common in psychiatric conditions, it is not surprising that patients with a mental health condition struggle to embrace ownership of their illness and engage in critical health behaviors—which may include adhering to medication regimens; maintaining a healthy sleep cycle, nutrition, and exercise routines; vigilant symptom surveillance; and carrying out an agreed-upon action plan.

Interventions

Professionally-guided “light-touch” interventions and technology-assisted self-management interventions also can improve patient engagement in activities through individual encounters, group forums, and technology-mediated exchanges, including telephone, email, text message, tele-health, and web-based interventions.¹³ The DE-STRESS (Delivery of Self Training and Education for Stressful Situations) model illustrates these principles. This 8-week program combines elements of face-to-face, email, telephone, and web-based assignments and exchanges, and demonstrates a decline in posttraumatic stress disorder, depression, and anxiety scores.¹⁴ Our Michigan Depression Outreach and Collaborative Care program is another example of a self-management intervention (Box 1).

Helping patients understand when common symptoms such as impaired concentration or dizziness should be “watched”—rather than responded to aggressively—is crucial for effective long-term management.

Challenges

Health care delivery and medical educational models have been slow to embrace this change to long-term care models because doing so involves what might be uncomfortable shifts in roles and responsibilities. Effective care for long-term illness necessitates that the patient become an expert on his (her) illness, and be an active participant and partner in their treatment. Preparing health professionals for this new role as teacher, mentor, and collaborator presents a challenge to health care systems and educational programs across disciplines.

When trying to facilitate effective patient-provider partnerships, it is important to recognize the variability in patient preference for what and how information is shared, how decisions are made, and the role patients are asked to play in their care. Patients differ in their desire for an active or collaborative shared-decision model; some prefer more directive provider communication and a passive role.¹⁸ Preferences are influenced by variables such as age, sex, race, anxiety level, and education.¹⁹ Open discussion of these matters between caregivers and patients is important; studies have shown that failure to address these issues of “fit” can
impede communication, healthy behavior, and positive outcomes.

Bottom Line

Emerging care models demand that health care providers become teachers and motivators to help patients develop and implement patterns of health surveillance and intervention that will optimize their well-being and functionality. As active collaborators in their care, patients form a partnership with their care teams, allowing for regular, reciprocal exchange of information and shared decision-making. This shift to a partnership creates new, exciting roles and responsibilities for all parties.

Related Resources

• Improving Chronic Illness Care. www.improvingchroniccare.org.
• Chronic disease self-management program (Better Choices, Better Health workshop). Stanford School of Medicine. http://patienteducation.stanford.edu/programs/cdsmp.html.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Featured Audio
Thomas E. Fluent, MD, talks about addressing patient resistance to a self-management model of care. Dr. Fluent is Clinical Assistant Professor, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.

Providing patients and their families with information and education about their psychiatric illness is a central tenet of mental health care. Discussions about diagnostic impressions, treatment options, and the risks and benefits of interventions are customary. Additionally, patients and families often receive written material or referral to other information sources, including self-help books and a growing number of online resources. Although patient education remains a useful and expected element of good care, there is evidence that, alone, it is insufficient to change health behaviors.¹

A growing body of literature and clinical experience suggests that self-management strategies complement patient education and improve treatment outcomes for patients with chronic illnesses, including psychiatric conditions.^2,3 The Cochrane Collaboration describes patient education as “teaching or training of patients concerning their own health needs,” and self-management as “the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a long-term disorder.”⁴

In this article, we review:

Principles of self-management

Chronic care models must account for conditions in which the clinical course can be variable, that are not amenable to a cure, and that demand long-term treatment. Optimal health outcomes rely on patients accurately monitoring, reporting, and responding to their symptoms, while engaging in critical health-related behaviors. In addition, clinicians must teach, partner with, and motivate patients to engage in crucial disease-management activities. Although typically not considered in this light, we believe most psychiatric disorders are best approached through a long-term care model, and benefit from self-management principles.

Basics of self-management include:

Corbin and Strauss believe effective “self-managers” achieve competency in three areas:

Proficiency in these three “self-manager” domains is enhanced by mastering five key self-management skills outlined in Table 1.⁷

Successful intervention programs vary widely with regard to individual vs group formats, communication interface, and involved health professionals. However, evidence indicates that problem solving, decision making, and action planning are key components.⁷ Successful planning includes:

Table 2 illustrates elements of successful action plans in our Action Planning Worksheet. Adapted from the work of Scharzer,⁸ Prochaska,⁹ and Clark,¹⁰ we developed this self-management tool for individual and group treatment settings. It serves as a vehicle for collaborative patient-provider discussion and planning. The nuts-and-bolts nature of the discussions inevitably leads to learning new, important, and often unexpected information about our patients’ daily lives and the challenges they face as they share their dominant priorities, fears, and insecurities.

Patients provide consistently positive feedback about action planning, and clinicians often find that the process reveals fruitful areas for further psychotherapeutic intervention. Examples include identifying a range of negative automatic thoughts or catastrophic thinking impeding initiation of important activation, and exposure activities for depressed or anxious patients.

Knowing what to do is different than actually doing it. Changing behavior is difficult in the best circumstances, let alone with the strain of a chronic illness. It is critical to recognize that the presence of depressive symptoms significantly reduces the likelihood that patients will employ self-management practices.¹¹ When combined with anxiety and the impairment of motivation and executive functioning that is common in psychiatric conditions, it is not surprising that patients with a mental health condition struggle to embrace ownership of their illness and engage in critical health behaviors—which may include adhering to medication regimens; maintaining a healthy sleep cycle, nutrition, and exercise routines; vigilant symptom surveillance; and carrying out an agreed-upon action plan.

Interventions

Professionally-guided “light-touch” interventions and technology-assisted self-management interventions also can improve patient engagement in activities through individual encounters, group forums, and technology-mediated exchanges, including telephone, email, text message, tele-health, and web-based interventions.¹³ The DE-STRESS (Delivery of Self Training and Education for Stressful Situations) model illustrates these principles. This 8-week program combines elements of face-to-face, email, telephone, and web-based assignments and exchanges, and demonstrates a decline in posttraumatic stress disorder, depression, and anxiety scores.¹⁴ Our Michigan Depression Outreach and Collaborative Care program is another example of a self-management intervention (Box 1).

Helping patients understand when common symptoms such as impaired concentration or dizziness should be “watched”—rather than responded to aggressively—is crucial for effective long-term management.

Challenges

Health care delivery and medical educational models have been slow to embrace this change to long-term care models because doing so involves what might be uncomfortable shifts in roles and responsibilities. Effective care for long-term illness necessitates that the patient become an expert on his (her) illness, and be an active participant and partner in their treatment. Preparing health professionals for this new role as teacher, mentor, and collaborator presents a challenge to health care systems and educational programs across disciplines.

When trying to facilitate effective patient-provider partnerships, it is important to recognize the variability in patient preference for what and how information is shared, how decisions are made, and the role patients are asked to play in their care. Patients differ in their desire for an active or collaborative shared-decision model; some prefer more directive provider communication and a passive role.¹⁸ Preferences are influenced by variables such as age, sex, race, anxiety level, and education.¹⁹ Open discussion of these matters between caregivers and patients is important; studies have shown that failure to address these issues of “fit” can
impede communication, healthy behavior, and positive outcomes.

Bottom Line

Emerging care models demand that health care providers become teachers and motivators to help patients develop and implement patterns of health surveillance and intervention that will optimize their well-being and functionality. As active collaborators in their care, patients form a partnership with their care teams, allowing for regular, reciprocal exchange of information and shared decision-making. This shift to a partnership creates new, exciting roles and responsibilities for all parties.

Related Resources

• Improving Chronic Illness Care. www.improvingchroniccare.org.
• Chronic disease self-management program (Better Choices, Better Health workshop). Stanford School of Medicine. http://patienteducation.stanford.edu/programs/cdsmp.html.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Featured Audio
Thomas E. Fluent, MD, talks about addressing patient resistance to a self-management model of care. Dr. Fluent is Clinical Assistant Professor, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.

Mr. H, age 31, is admitted to an acute psychiatric unit with major depressive disorder, substance dependence, insomnia, and generalized anxiety. In the past, he was treated unsuccessfully with sertraline, fluoxetine, clonazepam, venlafaxine, and lithium. The treatment team starts Mr. H on quetiapine, titrated to 150 mg at bedtime, to address suspected bipolar II disorder.

At baseline, Mr. H is 68 inches tall and slightly overweight at 176 lbs (body mass index [BMI] 26.8 kg/m²). The laboratory reports his glycated hemoglobin (HbA_1c) at 5.4%; low-density lipoprotein (LDL), 60 mg/dL; total cholesterol, 122 mg/dL; triglycerides, 141 mg/dL; and high-density lipoprotein (HDL), 34 mg/dL.

Within 1 month, Mr. H experiences a 16% increase in body weight. HbA_1c increases to 5.6%; LDL, to 93 mg/dL. These metabolic changes are not addressed, and he continues quetiapine for another 5 months. At the end of 6 months, Mr. H weighs 223.8 lbs (BMI 34 kg/m²)—a 27% increase from baseline. HbA_1c is in the prediabetic range, at 5.9%, and LDL is 120 mg/dL.¹ The treatment team discusses the risks of further metabolic effects, cardiovascular disease, and diabetes with Mr. H. He agrees to a change in therapy.

An increase in weight is thought to be associated with the actions of antipsychotics on H1and 5-HT2c receptors.⁷ Clozapine and olanzapine pose the highest risk of weight gain. Quetiapine and risperidone are considered of intermediate risk; aripiprazole and ziprasidone present the lowest risk(Table 1).^5,7

Patients taking an atypical antipsychotic may experience an elevation of blood glucose, serum Practice Points

• All atypical antipsychotics carry a risk of metabolic disturbance; clozapine and olanzapine have the highest risk, followed by quetiapine and risperidone.
• Newer atypical antipsychotics may carry less of a risk of metabolic side effects, but long-term data are lacking.
• Obtain baseline and periodic monitoring of BMI, waist circumference, HbA1c, fasting plasma glucose, and fasting lipids.
• If you find an abnormality of any of these parameters, consider one or more of the following: switching to an agent that is less risky; decreasing the dose or discontinuing therapy; recommending diet and exercise; and referring the patient to a program or clinician with expertise in the management of weight, diabetes, or lipids.
• Use monotherapy when appropriate to decrease the risk of side effects.triglyceride, and LDL levels, and a decrease in the HDL level.² These effects may be seen without an increase in BMI, and should be considered a direct effect of the antipsychotic.⁵ Although the mechanism by which dyslipidemia occurs is poorly understood, an increase in the blood glucose level is thought to be, in part, mediated by antagonism of M3 muscarinic receptors on pancreatic â-cells.⁷ Clozapine and olanzapine pose the highest risk of dyslipidemia. Quetiapine and risperidone are considered of intermediate risk; the risk associated with quetiapine is closer to that of olanzpine.^8,9 Aripiprazole and ziprasidone present a lower risk of dyslipidemia and glucose elevations.⁵

Newer atypical antipsychotics, such as asenapine, iloperidone, paliperidone, and lurasidone, seem to have a lower metabolic risk profile, similar to those seen with aripiprazole and ziprasidone.⁵ Patients enrolled in initial clinical trials might not be antipsychotic naïve, however, and may have been taking a high metabolic risk antipsychotic. When these patients are switched to an antipsychotic that carries less of a metabolic risk, it might appear that they are experiencing a decrease in metabolic adverse events.

Metabolic data on newer atypical antipsychotics are limited; most have not been subject to long-term study. Routine monitoring of metabolic side effects is recommended for all atypical antipsychotics, regardless of risk profile.

Recommended monitoring

Because of the known metabolic side effects that occur in patients taking an atypical antipsychotic, baseline and periodic monitoring is recommended (Table 2).^2,10 BMI and waist circumference should be recorded at baseline and tracked throughout treatment. Ideally, obtain measurements monthly for the first 3 months of therapy, or after any medication adjustments, then at 6 months, and annually thereafter. Encourage patients to track their own weight.

HbA_1c and fasting plasma glucose levels should be measured at baseline and throughout the course of treatment. Obtain another set of measurements at 3 months, then annually thereafter, unless the patient develops type 2 diabetes mellitus.²

Obtaining a fasting lipid panel at baseline and periodically throughout the course of treatment is recommended. After baseline measurement, another panel should be taken at 3 months and annually thereafter. Guidelines of the American Diabetes Association recommend a fasting lipid panel every 5 years—however, good clinical practice dictates obtaining a lipid panel annually.

Managing metabolic side effects

Assess whether the patient can benefit from a lower dosage of current medication, switching to an antipsychotic with less of a risk of metabolic disturbance, or from discontinuation of therapy. In most cases, aim to use monotherapy because polypharmacy contributes to an increased risk of side effects.10

Weight management. Recommend nutrition counseling and physical activity for all patients who are overweight. Referral to a health care professional or to a program with expertise in weight management also might be beneficial.² Include family members and significant others in the patient’s education when possible.

Impaired fasting glucose. Encourage a low-carbohydrate, high-protein diet with high intake of vegetables. Patients should obtain at least 30 minutes of physical activity, five times a week. Referral to a diabetes self-management class also is appropriate. Consider referral to a primary care physician or a clinician with expertise in diabetes.²

Impaired fasting lipids. Encourage your patients to adhere to a heart-healthy diet that is low in saturated fats and to get adequate physical activity. Referral to a dietician and primary care provider for medical management of dyslipidemia might be appropriate.²

Related Resources

• American Diabetes Association. Guide to living with diabetes. www.diabetes.org/living-with-diabetes.
• MOVE! Weight Management Program for Veterans. www. move.va.gov.

Drug Brand Names

Aripiprazole • Abilify
Asenapine • Saphris
Clonazepam • Klonopin
Clozapine • Clozaril
Fluoxetine • Prozac
Iloperidone • Fanapt
Lithium • Eskalith, Lithobid
Lurasidone • Latuda
Olanzapine • Zyprexa
Paliperidone • Invega
Quetiapine • Seroquel
Risperidone • Risperdal
Sertraline • Zoloft
Venlafaxine • Effexor
Ziprasidone • Geodon

Disclosure

The authors report no financial relationships with any of the manufacturers mentioned in this article or with manufacturers of competing products.

Mr. H, age 31, is admitted to an acute psychiatric unit with major depressive disorder, substance dependence, insomnia, and generalized anxiety. In the past, he was treated unsuccessfully with sertraline, fluoxetine, clonazepam, venlafaxine, and lithium. The treatment team starts Mr. H on quetiapine, titrated to 150 mg at bedtime, to address suspected bipolar II disorder.

At baseline, Mr. H is 68 inches tall and slightly overweight at 176 lbs (body mass index [BMI] 26.8 kg/m²). The laboratory reports his glycated hemoglobin (HbA_1c) at 5.4%; low-density lipoprotein (LDL), 60 mg/dL; total cholesterol, 122 mg/dL; triglycerides, 141 mg/dL; and high-density lipoprotein (HDL), 34 mg/dL.

Within 1 month, Mr. H experiences a 16% increase in body weight. HbA_1c increases to 5.6%; LDL, to 93 mg/dL. These metabolic changes are not addressed, and he continues quetiapine for another 5 months. At the end of 6 months, Mr. H weighs 223.8 lbs (BMI 34 kg/m²)—a 27% increase from baseline. HbA_1c is in the prediabetic range, at 5.9%, and LDL is 120 mg/dL.¹ The treatment team discusses the risks of further metabolic effects, cardiovascular disease, and diabetes with Mr. H. He agrees to a change in therapy.

An increase in weight is thought to be associated with the actions of antipsychotics on H1and 5-HT2c receptors.⁷ Clozapine and olanzapine pose the highest risk of weight gain. Quetiapine and risperidone are considered of intermediate risk; aripiprazole and ziprasidone present the lowest risk(Table 1).^5,7

Patients taking an atypical antipsychotic may experience an elevation of blood glucose, serum Practice Points

• All atypical antipsychotics carry a risk of metabolic disturbance; clozapine and olanzapine have the highest risk, followed by quetiapine and risperidone.
• Newer atypical antipsychotics may carry less of a risk of metabolic side effects, but long-term data are lacking.
• Obtain baseline and periodic monitoring of BMI, waist circumference, HbA1c, fasting plasma glucose, and fasting lipids.
• If you find an abnormality of any of these parameters, consider one or more of the following: switching to an agent that is less risky; decreasing the dose or discontinuing therapy; recommending diet and exercise; and referring the patient to a program or clinician with expertise in the management of weight, diabetes, or lipids.
• Use monotherapy when appropriate to decrease the risk of side effects.triglyceride, and LDL levels, and a decrease in the HDL level.² These effects may be seen without an increase in BMI, and should be considered a direct effect of the antipsychotic.⁵ Although the mechanism by which dyslipidemia occurs is poorly understood, an increase in the blood glucose level is thought to be, in part, mediated by antagonism of M3 muscarinic receptors on pancreatic â-cells.⁷ Clozapine and olanzapine pose the highest risk of dyslipidemia. Quetiapine and risperidone are considered of intermediate risk; the risk associated with quetiapine is closer to that of olanzpine.^8,9 Aripiprazole and ziprasidone present a lower risk of dyslipidemia and glucose elevations.⁵

Newer atypical antipsychotics, such as asenapine, iloperidone, paliperidone, and lurasidone, seem to have a lower metabolic risk profile, similar to those seen with aripiprazole and ziprasidone.⁵ Patients enrolled in initial clinical trials might not be antipsychotic naïve, however, and may have been taking a high metabolic risk antipsychotic. When these patients are switched to an antipsychotic that carries less of a metabolic risk, it might appear that they are experiencing a decrease in metabolic adverse events.

Metabolic data on newer atypical antipsychotics are limited; most have not been subject to long-term study. Routine monitoring of metabolic side effects is recommended for all atypical antipsychotics, regardless of risk profile.

Recommended monitoring

Because of the known metabolic side effects that occur in patients taking an atypical antipsychotic, baseline and periodic monitoring is recommended (Table 2).^2,10 BMI and waist circumference should be recorded at baseline and tracked throughout treatment. Ideally, obtain measurements monthly for the first 3 months of therapy, or after any medication adjustments, then at 6 months, and annually thereafter. Encourage patients to track their own weight.

HbA_1c and fasting plasma glucose levels should be measured at baseline and throughout the course of treatment. Obtain another set of measurements at 3 months, then annually thereafter, unless the patient develops type 2 diabetes mellitus.²

Obtaining a fasting lipid panel at baseline and periodically throughout the course of treatment is recommended. After baseline measurement, another panel should be taken at 3 months and annually thereafter. Guidelines of the American Diabetes Association recommend a fasting lipid panel every 5 years—however, good clinical practice dictates obtaining a lipid panel annually.

Managing metabolic side effects

Assess whether the patient can benefit from a lower dosage of current medication, switching to an antipsychotic with less of a risk of metabolic disturbance, or from discontinuation of therapy. In most cases, aim to use monotherapy because polypharmacy contributes to an increased risk of side effects.10

Weight management. Recommend nutrition counseling and physical activity for all patients who are overweight. Referral to a health care professional or to a program with expertise in weight management also might be beneficial.² Include family members and significant others in the patient’s education when possible.

Impaired fasting glucose. Encourage a low-carbohydrate, high-protein diet with high intake of vegetables. Patients should obtain at least 30 minutes of physical activity, five times a week. Referral to a diabetes self-management class also is appropriate. Consider referral to a primary care physician or a clinician with expertise in diabetes.²

Impaired fasting lipids. Encourage your patients to adhere to a heart-healthy diet that is low in saturated fats and to get adequate physical activity. Referral to a dietician and primary care provider for medical management of dyslipidemia might be appropriate.²

Related Resources

• American Diabetes Association. Guide to living with diabetes. www.diabetes.org/living-with-diabetes.
• MOVE! Weight Management Program for Veterans. www. move.va.gov.

Drug Brand Names

Aripiprazole • Abilify
Asenapine • Saphris
Clonazepam • Klonopin
Clozapine • Clozaril
Fluoxetine • Prozac
Iloperidone • Fanapt
Lithium • Eskalith, Lithobid
Lurasidone • Latuda
Olanzapine • Zyprexa
Paliperidone • Invega
Quetiapine • Seroquel
Risperidone • Risperdal
Sertraline • Zoloft
Venlafaxine • Effexor
Ziprasidone • Geodon

Disclosure

The authors report no financial relationships with any of the manufacturers mentioned in this article or with manufacturers of competing products.

Mr. H, age 31, is admitted to an acute psychiatric unit with major depressive disorder, substance dependence, insomnia, and generalized anxiety. In the past, he was treated unsuccessfully with sertraline, fluoxetine, clonazepam, venlafaxine, and lithium. The treatment team starts Mr. H on quetiapine, titrated to 150 mg at bedtime, to address suspected bipolar II disorder.

At baseline, Mr. H is 68 inches tall and slightly overweight at 176 lbs (body mass index [BMI] 26.8 kg/m²). The laboratory reports his glycated hemoglobin (HbA_1c) at 5.4%; low-density lipoprotein (LDL), 60 mg/dL; total cholesterol, 122 mg/dL; triglycerides, 141 mg/dL; and high-density lipoprotein (HDL), 34 mg/dL.

Within 1 month, Mr. H experiences a 16% increase in body weight. HbA_1c increases to 5.6%; LDL, to 93 mg/dL. These metabolic changes are not addressed, and he continues quetiapine for another 5 months. At the end of 6 months, Mr. H weighs 223.8 lbs (BMI 34 kg/m²)—a 27% increase from baseline. HbA_1c is in the prediabetic range, at 5.9%, and LDL is 120 mg/dL.¹ The treatment team discusses the risks of further metabolic effects, cardiovascular disease, and diabetes with Mr. H. He agrees to a change in therapy.

An increase in weight is thought to be associated with the actions of antipsychotics on H1and 5-HT2c receptors.⁷ Clozapine and olanzapine pose the highest risk of weight gain. Quetiapine and risperidone are considered of intermediate risk; aripiprazole and ziprasidone present the lowest risk(Table 1).^5,7

Patients taking an atypical antipsychotic may experience an elevation of blood glucose, serum Practice Points

• All atypical antipsychotics carry a risk of metabolic disturbance; clozapine and olanzapine have the highest risk, followed by quetiapine and risperidone.
• Newer atypical antipsychotics may carry less of a risk of metabolic side effects, but long-term data are lacking.
• Obtain baseline and periodic monitoring of BMI, waist circumference, HbA1c, fasting plasma glucose, and fasting lipids.
• If you find an abnormality of any of these parameters, consider one or more of the following: switching to an agent that is less risky; decreasing the dose or discontinuing therapy; recommending diet and exercise; and referring the patient to a program or clinician with expertise in the management of weight, diabetes, or lipids.
• Use monotherapy when appropriate to decrease the risk of side effects.triglyceride, and LDL levels, and a decrease in the HDL level.² These effects may be seen without an increase in BMI, and should be considered a direct effect of the antipsychotic.⁵ Although the mechanism by which dyslipidemia occurs is poorly understood, an increase in the blood glucose level is thought to be, in part, mediated by antagonism of M3 muscarinic receptors on pancreatic â-cells.⁷ Clozapine and olanzapine pose the highest risk of dyslipidemia. Quetiapine and risperidone are considered of intermediate risk; the risk associated with quetiapine is closer to that of olanzpine.^8,9 Aripiprazole and ziprasidone present a lower risk of dyslipidemia and glucose elevations.⁵

Newer atypical antipsychotics, such as asenapine, iloperidone, paliperidone, and lurasidone, seem to have a lower metabolic risk profile, similar to those seen with aripiprazole and ziprasidone.⁵ Patients enrolled in initial clinical trials might not be antipsychotic naïve, however, and may have been taking a high metabolic risk antipsychotic. When these patients are switched to an antipsychotic that carries less of a metabolic risk, it might appear that they are experiencing a decrease in metabolic adverse events.

Metabolic data on newer atypical antipsychotics are limited; most have not been subject to long-term study. Routine monitoring of metabolic side effects is recommended for all atypical antipsychotics, regardless of risk profile.

Recommended monitoring

Because of the known metabolic side effects that occur in patients taking an atypical antipsychotic, baseline and periodic monitoring is recommended (Table 2).^2,10 BMI and waist circumference should be recorded at baseline and tracked throughout treatment. Ideally, obtain measurements monthly for the first 3 months of therapy, or after any medication adjustments, then at 6 months, and annually thereafter. Encourage patients to track their own weight.

HbA_1c and fasting plasma glucose levels should be measured at baseline and throughout the course of treatment. Obtain another set of measurements at 3 months, then annually thereafter, unless the patient develops type 2 diabetes mellitus.²

Obtaining a fasting lipid panel at baseline and periodically throughout the course of treatment is recommended. After baseline measurement, another panel should be taken at 3 months and annually thereafter. Guidelines of the American Diabetes Association recommend a fasting lipid panel every 5 years—however, good clinical practice dictates obtaining a lipid panel annually.

Managing metabolic side effects

Assess whether the patient can benefit from a lower dosage of current medication, switching to an antipsychotic with less of a risk of metabolic disturbance, or from discontinuation of therapy. In most cases, aim to use monotherapy because polypharmacy contributes to an increased risk of side effects.10

Weight management. Recommend nutrition counseling and physical activity for all patients who are overweight. Referral to a health care professional or to a program with expertise in weight management also might be beneficial.² Include family members and significant others in the patient’s education when possible.

Impaired fasting glucose. Encourage a low-carbohydrate, high-protein diet with high intake of vegetables. Patients should obtain at least 30 minutes of physical activity, five times a week. Referral to a diabetes self-management class also is appropriate. Consider referral to a primary care physician or a clinician with expertise in diabetes.²

Impaired fasting lipids. Encourage your patients to adhere to a heart-healthy diet that is low in saturated fats and to get adequate physical activity. Referral to a dietician and primary care provider for medical management of dyslipidemia might be appropriate.²

Related Resources

• American Diabetes Association. Guide to living with diabetes. www.diabetes.org/living-with-diabetes.
• MOVE! Weight Management Program for Veterans. www. move.va.gov.

Drug Brand Names

Aripiprazole • Abilify
Asenapine • Saphris
Clonazepam • Klonopin
Clozapine • Clozaril
Fluoxetine • Prozac
Iloperidone • Fanapt
Lithium • Eskalith, Lithobid
Lurasidone • Latuda
Olanzapine • Zyprexa
Paliperidone • Invega
Quetiapine • Seroquel
Risperidone • Risperdal
Sertraline • Zoloft
Venlafaxine • Effexor
Ziprasidone • Geodon

Disclosure

The authors report no financial relationships with any of the manufacturers mentioned in this article or with manufacturers of competing products.

Depression is highly prevalent in hospice and palliative care settings—especially among cancer patients, in whom the prevalence of depression may be 4 times that of the general population.¹ Furthermore, suicide is a relatively common, unwanted consequence of depression among cancer patients.² Whereas the risk of suicide among advanced cancer patients may be twice that of the general population,³ in specific cancer populations (male patients with pancreatic adenocarcinoma) the risk of suicide may be 11 times that of the general population.⁴

Mental health professionals often are consulted when treating depressed patients with advanced illness, especially when suicidal thoughts or wishes for a hastened death are expressed to oncologists or primary care physicians. To mitigate the effects of depression among seriously ill patients (Box),^5,6 mental health professionals must be able to assess and manage depression in patients with progressive, incurable illnesses such as advanced malignancy.

Diagnostic challenges

Assessing depression in seriously ill patients can be a challenge for mental health professionals. Cardinal neurovegetative symptoms of depression, such as anergia, anorexia, impaired concentration, and sleep disturbances, also are common manifestations of advanced medical illness.⁷ Furthermore, it can be difficult to gauge the significance of psychological distress among cancer patients. Although depressive thoughts and symptoms may be present in 15% to 50% of cancer patients, only 5% to 20% will meet diagnostic criteria for major depressive disorder (MDD).^8,9 You may find it challenging to determine whether to use pharmacotherapy for depressive symptoms or whether engaging in reflective listening and exploring the patient’s concerns is the appropriate therapeutic intervention.

Side effects from commonly used therapeutics for cancer patients—chemotherapeutic agents, opioids, benzodiazepines, glucocorticoids—can mimic depressive symptoms. Clinicians should include hypoactive delirium in the differential diagnosis of depressive symptoms in cancer patients. Delirium is an important consideration in the final days of life because the condition has been shown to occur in as many as 90% of these patients.¹⁰ A mistaken diagnosis of depression in a patient who has hypoactive delirium (see “Hospitalized, elderly, and delirious: What should you do for these patients?” page 10) might lead to a prescription for an antidepressant or a psychostimulant, which can exacerbate delirium rather than alleviate depressive symptoms.

Significant attitudinal barriers from both clinicians and patients can lead to under-
recognition and undertreatment of depression. Clinicians may believe the patient’s depression is an appropriate response to the dying process; indeed, feeling sad or depressed may be an appropriate response to bad news or a medical setback, but meeting MDD criteria should be viewed as a pathologic process that has adverse medical, psychological, and social consequences. Time constraints or personal discomfort with existential concerns may prevent a clinician from exploring a patient’s distress out of fear that such discussions may cause the patient to become more depressed.¹¹ Patients may underreport or consciously disguise depressive symptoms in their final weeks of life.¹²

Responding to these challenges

The Science Committee of the Association of Palliative Medicine performed a thorough assessment of available screening tools and rating scales for depressive symptoms in palliative care. Although the committee found that commonly used tools such as the Edinburgh Depression Scale and the Hospital Anxiety and Depression Scale have validated cutoff thresholds for palliative care patients, the depression screening tool with the highest sensitivity, specificity, and positive predictive value was the question: “Are you feeling down, depressed, or hopeless most of the time over the last 2 weeks?”^13,14

Other short screening algorithms have been validated among palliative care patients (Table 1).¹⁵ Endicott proposed a structured approach to help clinicians differentiate MDD from common physical ailments of progressive cancer in which physical criteria for an MDD diagnosis are substituted by affective symptoms (Table 2).¹⁶ The improved risk-benefit ratio of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), coupled with the potential significant morbidity associated with MDD and subsyndromal depressive symptoms, makes it necessary to recognize and treat those symptoms even when the cause of the depressive symptoms is unclear.

Psychotherapy in palliative care

Psychotherapeutic interventions such as dignity therapy, which invites patients to utilize a meaning-centered life review to address his (her) existential concerns, may help depressed palliative care patients.¹⁷ Evidence suggests a strong association between diminished dignity and depression in patients with advanced illness.¹⁸ Individualized psychotherapeutic interventions that provide a framework for addressing dignity-related issues and existential distress among terminally ill patients could help preserve a sense of purpose throughout the dying process. Surveys of dignity therapy have been encouraging: 91% of participants reported being satisfied with dignity therapy and more than two-thirds reported an improved sense of meaning.¹⁸

Other promising psychotherapeutic interventions include supportive-expressed group therapy, in which a group of advanced cancer patients meets with a mental health professional and discusses goals of building bonds, refining life’s priorities, and “detoxifying” the experience of death and dying.¹⁹ A primary purpose of this therapy is not just to foster improved relationships within a group of cancer patients, but also within their family and oncology team, with the aim of improving compliance with anti­cancer therapies. Nurse-delivered, one-on-one sessions focusing on depression education, problem-solving, coping techniques, and telecare management of pain and depression also improves outcomes among depressed cancer patients.²⁰

Hospital-based inpatient and outpatient palliative care consultation teams are becoming more common. A randomized controlled trial of early palliative care outpatient consultation for patients with incurable lung cancer showed improved depression outcomes, better quality of life, and a modest improvement in survival.²¹ Although the most effective elements of a palliative care consult remain unspecified and require further research, improvement in outcomes may result from more effective symptom management, better acknowledgement of the burden of illness on the patient or family, or reduced need for hospitalization. Therefore, mental health professionals should consider palliative care consultation for advanced cancer patients with signs of psychological distress.

Pharmacotherapy options

Antidepressants. Patients with excessive guilt, anhedonia, hopelessness, or ruminative thinking along with a related impairment in quality of life may benefit from pharmacotherapy regardless of whether they meet diagnostic criteria for MDD. Although SSRIs and SNRIs have become a mainstay in managing depression, placebo-controlled trials have yielded mixed results in depressed cancer patients. Furthermore, differences in efficacy among these antidepressants may not be significant, according to a recent meta-analysis.²²

Select an antidepressant based on the patient’s past treatment response, target symptoms, and potential for adverse events. Mirtazapine has relatively few drug interactions; the side effects of sedation and weight gain may be welcome among patients with insomnia and impaired appetite.²³ Furthermore, mirtazapine is a 5-HT3 receptor antagonist,²⁴ which suggests it might act as an effective antiemetic.²⁵ Other SNRIs, such as venlafaxine and duloxetine, have demonstrated benefits in managing neuropathic pain in patients who do not have cancer.²⁶

Psychostimulants. Patients with a prognosis of days or weeks might not have enough time for an antidepressant to achieve full effect. Open prospective trials and pilot studies have shown that psychostimulants can improve cancer-related fatigue and quality of life while also augmenting the action of antidepressants.²⁷ Psychostimulants, such as methylphenidate, have been used for treating cancer-related fatigue and depressive symptoms in medically ill patients. Their rapid onset of action, coupled with minimal side effect profile, make them a good choice for seriously ill patients with significant neurovegetative symptoms of a depressive disorder. Note: Avoid psychostimulants in patients with delirium and use with caution in patients with heart disease.²⁸

Novel agents. A growing body of preclinical research suggests that glutamate may be involved in the pathophysiology of MDD. Ketamine modulates glutamate neurotransmission as an N-methyl-d-aspartate receptor antagonist. A recent evaluation of a single dose IV of ketamine in a placebo-controlled, double-blind trial found that depressed patients receiving ketamine experienced significant improvement their depressive symptoms.²⁹ Irwin and Iglewicz³⁰ describe 2 hospice patients administered a single oral dose of ketamine, which provided rapid relief of depressive symptoms and was well tolerated.

Transdermal selegiline may help patients who have trouble taking oral medications, including antidepressants. Inability to tolerate or absorb medications may be related to several conditions such as head and neck cancer, severe mucositis, and dysphagia. The dose-related dietary requirements—tyramine restriction—and careful monitoring for drug interactions may limit the use of selegiline in medically ill patients.³¹Table 3 features a list of dosing recommendations for pharmacotherapeutic options.³²

Use the strategy of “start low, go slow” when initiating and adjusting antidepressants because patients with cancer and other advanced illnesses often have concomitant organ failure and are at risk of drug interactions. Carefully review your patient’s medication list for agents that are no longer beneficial or possibly contributing to depressive symptoms to help reduce the risk of adverse pharmacokinetic and pharmaco-dynamic interactions.

Requests for a hastened death

As many as 8.5% of terminally ill patients have a sustained and pervasive wish for an early death.³³ Although requests for a hastened death may evoke strong emotional reactions and compel many clinicians to recoil or harshly reject such requests, consider such requests as an opportunity to gain insight into the patient’s narrative of his (her) suffering. The clinician’s role in such cases is to identify suicidality and perform a thorough suicide risk assessment. Interventions to prevent suicide should attempt to balance the seriousness of self-harm threats with restrictions on the patient’s liberty.³⁴

Clinicians also need to consider the patient’s prognosis in their decision-making. For example, an extremely depressed or suicidal patient may not benefit from psychiatric hospitalization if she (he) has progressive neurovegetative symptoms and a prognosis of only a few weeks to live. These situations often are challenging and require a careful, informed discussion of the risks and benefits of all proposed interventions.

Clinicians also should be familiar with distinctions among ethical issues in end-of-life care, including physician-assisted suicide, euthanasia, and palliative sedation (Table 4).^35,36

In Oregon, requests for physician-assisted suicide and hastened death through the state’s Death with Dignity Act often are short lived, and may not persist when clinicians offer patients good symptom management and psychological support.³⁷ Requests for a hastened death often are motivated by loss of control, inability to find meaning in death, indignity from being dependent, and concern for future suffering and burden on loved ones.³⁷

Carefully evaluate requests for hastened death in a manner that balances your personal and professional integrity. To preserve personal integrity, clearly communicate therapeutic interventions that you can and cannot provide. To ensure the patient does not feel abandoned, identify factors that contribute to the patient’s suffering and express a desire to search for alternative care approaches that will be mutually acceptable to the patient and to you.

Advance care planning and palliative care consultations may help in these circumstances. A randomized trial comparing advance care planning vs standard care in hospitalized geriatric patients found that advance care planning was more likely to lead to end-of-life wishes that were recognized by clinicians, and was associated with less distress, anxiety, and depression as reported by bereaved family members.³⁸

Clinicians can assist patients with advanced care planning by helping them fill out advance directives, such as durable health care power of attorney documents and a living will. Palliative care clinicians can offer specialty-level assistance in advance care planning, provide focused assessments of physical and psychosocial symptoms, develop appropriate clinical goals, and assist in coordinating individualized care plans for seriously ill patients.²

Bottom Line

Depression commonly is encountered in hospice and palliative care patients and is associated with morbidity and distress. Validated screening tools can help you distinguish major depressive disorder from depressive symptoms in this population. Several psychotherapeutic techniques have been shown to be beneficial. In addition to traditional antidepressants, psychostimulants or ketamine may help address acute depressive symptoms in patients who have days or weeks to live.

Related Resources

• American Academy of Hospice and Palliative Medicine. www.aahpm.org.
• Death with Dignity National Center. www.deathwithdignity.org.
• National Hospice and Palliative Care Organization. www.nhpco.org.
• Oregon Health Authority. Death with Dignity Act. http://public.health.oregon.gov/ProviderPartnerResources/Evaluationresearch/deathwithdignityact/Pages/index.aspx.

Drug Brand Names

Duloxetine • Cymbalta                        Modafinil • Provigil

Ketamine • Ketalar                             Selegiline (transdermal) • EMSAM

Methylphenidate  • Concerta, Ritalin     Mirtazipine • Remeron

Venlafaxine • Effexor                                    

Disclosures

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Depression is highly prevalent in hospice and palliative care settings—especially among cancer patients, in whom the prevalence of depression may be 4 times that of the general population.¹ Furthermore, suicide is a relatively common, unwanted consequence of depression among cancer patients.² Whereas the risk of suicide among advanced cancer patients may be twice that of the general population,³ in specific cancer populations (male patients with pancreatic adenocarcinoma) the risk of suicide may be 11 times that of the general population.⁴

Mental health professionals often are consulted when treating depressed patients with advanced illness, especially when suicidal thoughts or wishes for a hastened death are expressed to oncologists or primary care physicians. To mitigate the effects of depression among seriously ill patients (Box),^5,6 mental health professionals must be able to assess and manage depression in patients with progressive, incurable illnesses such as advanced malignancy.

Diagnostic challenges

Assessing depression in seriously ill patients can be a challenge for mental health professionals. Cardinal neurovegetative symptoms of depression, such as anergia, anorexia, impaired concentration, and sleep disturbances, also are common manifestations of advanced medical illness.⁷ Furthermore, it can be difficult to gauge the significance of psychological distress among cancer patients. Although depressive thoughts and symptoms may be present in 15% to 50% of cancer patients, only 5% to 20% will meet diagnostic criteria for major depressive disorder (MDD).^8,9 You may find it challenging to determine whether to use pharmacotherapy for depressive symptoms or whether engaging in reflective listening and exploring the patient’s concerns is the appropriate therapeutic intervention.

Side effects from commonly used therapeutics for cancer patients—chemotherapeutic agents, opioids, benzodiazepines, glucocorticoids—can mimic depressive symptoms. Clinicians should include hypoactive delirium in the differential diagnosis of depressive symptoms in cancer patients. Delirium is an important consideration in the final days of life because the condition has been shown to occur in as many as 90% of these patients.¹⁰ A mistaken diagnosis of depression in a patient who has hypoactive delirium (see “Hospitalized, elderly, and delirious: What should you do for these patients?” page 10) might lead to a prescription for an antidepressant or a psychostimulant, which can exacerbate delirium rather than alleviate depressive symptoms.

Significant attitudinal barriers from both clinicians and patients can lead to under-
recognition and undertreatment of depression. Clinicians may believe the patient’s depression is an appropriate response to the dying process; indeed, feeling sad or depressed may be an appropriate response to bad news or a medical setback, but meeting MDD criteria should be viewed as a pathologic process that has adverse medical, psychological, and social consequences. Time constraints or personal discomfort with existential concerns may prevent a clinician from exploring a patient’s distress out of fear that such discussions may cause the patient to become more depressed.¹¹ Patients may underreport or consciously disguise depressive symptoms in their final weeks of life.¹²

Responding to these challenges

The Science Committee of the Association of Palliative Medicine performed a thorough assessment of available screening tools and rating scales for depressive symptoms in palliative care. Although the committee found that commonly used tools such as the Edinburgh Depression Scale and the Hospital Anxiety and Depression Scale have validated cutoff thresholds for palliative care patients, the depression screening tool with the highest sensitivity, specificity, and positive predictive value was the question: “Are you feeling down, depressed, or hopeless most of the time over the last 2 weeks?”^13,14

Other short screening algorithms have been validated among palliative care patients (Table 1).¹⁵ Endicott proposed a structured approach to help clinicians differentiate MDD from common physical ailments of progressive cancer in which physical criteria for an MDD diagnosis are substituted by affective symptoms (Table 2).¹⁶ The improved risk-benefit ratio of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), coupled with the potential significant morbidity associated with MDD and subsyndromal depressive symptoms, makes it necessary to recognize and treat those symptoms even when the cause of the depressive symptoms is unclear.

Psychotherapy in palliative care

Psychotherapeutic interventions such as dignity therapy, which invites patients to utilize a meaning-centered life review to address his (her) existential concerns, may help depressed palliative care patients.¹⁷ Evidence suggests a strong association between diminished dignity and depression in patients with advanced illness.¹⁸ Individualized psychotherapeutic interventions that provide a framework for addressing dignity-related issues and existential distress among terminally ill patients could help preserve a sense of purpose throughout the dying process. Surveys of dignity therapy have been encouraging: 91% of participants reported being satisfied with dignity therapy and more than two-thirds reported an improved sense of meaning.¹⁸

Other promising psychotherapeutic interventions include supportive-expressed group therapy, in which a group of advanced cancer patients meets with a mental health professional and discusses goals of building bonds, refining life’s priorities, and “detoxifying” the experience of death and dying.¹⁹ A primary purpose of this therapy is not just to foster improved relationships within a group of cancer patients, but also within their family and oncology team, with the aim of improving compliance with anti­cancer therapies. Nurse-delivered, one-on-one sessions focusing on depression education, problem-solving, coping techniques, and telecare management of pain and depression also improves outcomes among depressed cancer patients.²⁰

Hospital-based inpatient and outpatient palliative care consultation teams are becoming more common. A randomized controlled trial of early palliative care outpatient consultation for patients with incurable lung cancer showed improved depression outcomes, better quality of life, and a modest improvement in survival.²¹ Although the most effective elements of a palliative care consult remain unspecified and require further research, improvement in outcomes may result from more effective symptom management, better acknowledgement of the burden of illness on the patient or family, or reduced need for hospitalization. Therefore, mental health professionals should consider palliative care consultation for advanced cancer patients with signs of psychological distress.

Pharmacotherapy options

Antidepressants. Patients with excessive guilt, anhedonia, hopelessness, or ruminative thinking along with a related impairment in quality of life may benefit from pharmacotherapy regardless of whether they meet diagnostic criteria for MDD. Although SSRIs and SNRIs have become a mainstay in managing depression, placebo-controlled trials have yielded mixed results in depressed cancer patients. Furthermore, differences in efficacy among these antidepressants may not be significant, according to a recent meta-analysis.²²

Select an antidepressant based on the patient’s past treatment response, target symptoms, and potential for adverse events. Mirtazapine has relatively few drug interactions; the side effects of sedation and weight gain may be welcome among patients with insomnia and impaired appetite.²³ Furthermore, mirtazapine is a 5-HT3 receptor antagonist,²⁴ which suggests it might act as an effective antiemetic.²⁵ Other SNRIs, such as venlafaxine and duloxetine, have demonstrated benefits in managing neuropathic pain in patients who do not have cancer.²⁶

Psychostimulants. Patients with a prognosis of days or weeks might not have enough time for an antidepressant to achieve full effect. Open prospective trials and pilot studies have shown that psychostimulants can improve cancer-related fatigue and quality of life while also augmenting the action of antidepressants.²⁷ Psychostimulants, such as methylphenidate, have been used for treating cancer-related fatigue and depressive symptoms in medically ill patients. Their rapid onset of action, coupled with minimal side effect profile, make them a good choice for seriously ill patients with significant neurovegetative symptoms of a depressive disorder. Note: Avoid psychostimulants in patients with delirium and use with caution in patients with heart disease.²⁸

Novel agents. A growing body of preclinical research suggests that glutamate may be involved in the pathophysiology of MDD. Ketamine modulates glutamate neurotransmission as an N-methyl-d-aspartate receptor antagonist. A recent evaluation of a single dose IV of ketamine in a placebo-controlled, double-blind trial found that depressed patients receiving ketamine experienced significant improvement their depressive symptoms.²⁹ Irwin and Iglewicz³⁰ describe 2 hospice patients administered a single oral dose of ketamine, which provided rapid relief of depressive symptoms and was well tolerated.

Transdermal selegiline may help patients who have trouble taking oral medications, including antidepressants. Inability to tolerate or absorb medications may be related to several conditions such as head and neck cancer, severe mucositis, and dysphagia. The dose-related dietary requirements—tyramine restriction—and careful monitoring for drug interactions may limit the use of selegiline in medically ill patients.³¹Table 3 features a list of dosing recommendations for pharmacotherapeutic options.³²

Use the strategy of “start low, go slow” when initiating and adjusting antidepressants because patients with cancer and other advanced illnesses often have concomitant organ failure and are at risk of drug interactions. Carefully review your patient’s medication list for agents that are no longer beneficial or possibly contributing to depressive symptoms to help reduce the risk of adverse pharmacokinetic and pharmaco-dynamic interactions.

Requests for a hastened death

As many as 8.5% of terminally ill patients have a sustained and pervasive wish for an early death.³³ Although requests for a hastened death may evoke strong emotional reactions and compel many clinicians to recoil or harshly reject such requests, consider such requests as an opportunity to gain insight into the patient’s narrative of his (her) suffering. The clinician’s role in such cases is to identify suicidality and perform a thorough suicide risk assessment. Interventions to prevent suicide should attempt to balance the seriousness of self-harm threats with restrictions on the patient’s liberty.³⁴

Clinicians also need to consider the patient’s prognosis in their decision-making. For example, an extremely depressed or suicidal patient may not benefit from psychiatric hospitalization if she (he) has progressive neurovegetative symptoms and a prognosis of only a few weeks to live. These situations often are challenging and require a careful, informed discussion of the risks and benefits of all proposed interventions.

Clinicians also should be familiar with distinctions among ethical issues in end-of-life care, including physician-assisted suicide, euthanasia, and palliative sedation (Table 4).^35,36

In Oregon, requests for physician-assisted suicide and hastened death through the state’s Death with Dignity Act often are short lived, and may not persist when clinicians offer patients good symptom management and psychological support.³⁷ Requests for a hastened death often are motivated by loss of control, inability to find meaning in death, indignity from being dependent, and concern for future suffering and burden on loved ones.³⁷

Carefully evaluate requests for hastened death in a manner that balances your personal and professional integrity. To preserve personal integrity, clearly communicate therapeutic interventions that you can and cannot provide. To ensure the patient does not feel abandoned, identify factors that contribute to the patient’s suffering and express a desire to search for alternative care approaches that will be mutually acceptable to the patient and to you.

Advance care planning and palliative care consultations may help in these circumstances. A randomized trial comparing advance care planning vs standard care in hospitalized geriatric patients found that advance care planning was more likely to lead to end-of-life wishes that were recognized by clinicians, and was associated with less distress, anxiety, and depression as reported by bereaved family members.³⁸

Clinicians can assist patients with advanced care planning by helping them fill out advance directives, such as durable health care power of attorney documents and a living will. Palliative care clinicians can offer specialty-level assistance in advance care planning, provide focused assessments of physical and psychosocial symptoms, develop appropriate clinical goals, and assist in coordinating individualized care plans for seriously ill patients.²

Bottom Line

Depression commonly is encountered in hospice and palliative care patients and is associated with morbidity and distress. Validated screening tools can help you distinguish major depressive disorder from depressive symptoms in this population. Several psychotherapeutic techniques have been shown to be beneficial. In addition to traditional antidepressants, psychostimulants or ketamine may help address acute depressive symptoms in patients who have days or weeks to live.

Related Resources

• American Academy of Hospice and Palliative Medicine. www.aahpm.org.
• Death with Dignity National Center. www.deathwithdignity.org.
• National Hospice and Palliative Care Organization. www.nhpco.org.
• Oregon Health Authority. Death with Dignity Act. http://public.health.oregon.gov/ProviderPartnerResources/Evaluationresearch/deathwithdignityact/Pages/index.aspx.

Drug Brand Names

Duloxetine • Cymbalta                        Modafinil • Provigil

Ketamine • Ketalar                             Selegiline (transdermal) • EMSAM

Methylphenidate  • Concerta, Ritalin     Mirtazipine • Remeron

Venlafaxine • Effexor                                    

Disclosures

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Depression is highly prevalent in hospice and palliative care settings—especially among cancer patients, in whom the prevalence of depression may be 4 times that of the general population.¹ Furthermore, suicide is a relatively common, unwanted consequence of depression among cancer patients.² Whereas the risk of suicide among advanced cancer patients may be twice that of the general population,³ in specific cancer populations (male patients with pancreatic adenocarcinoma) the risk of suicide may be 11 times that of the general population.⁴

Mental health professionals often are consulted when treating depressed patients with advanced illness, especially when suicidal thoughts or wishes for a hastened death are expressed to oncologists or primary care physicians. To mitigate the effects of depression among seriously ill patients (Box),^5,6 mental health professionals must be able to assess and manage depression in patients with progressive, incurable illnesses such as advanced malignancy.

Diagnostic challenges

Assessing depression in seriously ill patients can be a challenge for mental health professionals. Cardinal neurovegetative symptoms of depression, such as anergia, anorexia, impaired concentration, and sleep disturbances, also are common manifestations of advanced medical illness.⁷ Furthermore, it can be difficult to gauge the significance of psychological distress among cancer patients. Although depressive thoughts and symptoms may be present in 15% to 50% of cancer patients, only 5% to 20% will meet diagnostic criteria for major depressive disorder (MDD).^8,9 You may find it challenging to determine whether to use pharmacotherapy for depressive symptoms or whether engaging in reflective listening and exploring the patient’s concerns is the appropriate therapeutic intervention.

Side effects from commonly used therapeutics for cancer patients—chemotherapeutic agents, opioids, benzodiazepines, glucocorticoids—can mimic depressive symptoms. Clinicians should include hypoactive delirium in the differential diagnosis of depressive symptoms in cancer patients. Delirium is an important consideration in the final days of life because the condition has been shown to occur in as many as 90% of these patients.¹⁰ A mistaken diagnosis of depression in a patient who has hypoactive delirium (see “Hospitalized, elderly, and delirious: What should you do for these patients?” page 10) might lead to a prescription for an antidepressant or a psychostimulant, which can exacerbate delirium rather than alleviate depressive symptoms.

Significant attitudinal barriers from both clinicians and patients can lead to under-
recognition and undertreatment of depression. Clinicians may believe the patient’s depression is an appropriate response to the dying process; indeed, feeling sad or depressed may be an appropriate response to bad news or a medical setback, but meeting MDD criteria should be viewed as a pathologic process that has adverse medical, psychological, and social consequences. Time constraints or personal discomfort with existential concerns may prevent a clinician from exploring a patient’s distress out of fear that such discussions may cause the patient to become more depressed.¹¹ Patients may underreport or consciously disguise depressive symptoms in their final weeks of life.¹²

Responding to these challenges

The Science Committee of the Association of Palliative Medicine performed a thorough assessment of available screening tools and rating scales for depressive symptoms in palliative care. Although the committee found that commonly used tools such as the Edinburgh Depression Scale and the Hospital Anxiety and Depression Scale have validated cutoff thresholds for palliative care patients, the depression screening tool with the highest sensitivity, specificity, and positive predictive value was the question: “Are you feeling down, depressed, or hopeless most of the time over the last 2 weeks?”^13,14

Other short screening algorithms have been validated among palliative care patients (Table 1).¹⁵ Endicott proposed a structured approach to help clinicians differentiate MDD from common physical ailments of progressive cancer in which physical criteria for an MDD diagnosis are substituted by affective symptoms (Table 2).¹⁶ The improved risk-benefit ratio of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), coupled with the potential significant morbidity associated with MDD and subsyndromal depressive symptoms, makes it necessary to recognize and treat those symptoms even when the cause of the depressive symptoms is unclear.

Psychotherapy in palliative care

Psychotherapeutic interventions such as dignity therapy, which invites patients to utilize a meaning-centered life review to address his (her) existential concerns, may help depressed palliative care patients.¹⁷ Evidence suggests a strong association between diminished dignity and depression in patients with advanced illness.¹⁸ Individualized psychotherapeutic interventions that provide a framework for addressing dignity-related issues and existential distress among terminally ill patients could help preserve a sense of purpose throughout the dying process. Surveys of dignity therapy have been encouraging: 91% of participants reported being satisfied with dignity therapy and more than two-thirds reported an improved sense of meaning.¹⁸

Other promising psychotherapeutic interventions include supportive-expressed group therapy, in which a group of advanced cancer patients meets with a mental health professional and discusses goals of building bonds, refining life’s priorities, and “detoxifying” the experience of death and dying.¹⁹ A primary purpose of this therapy is not just to foster improved relationships within a group of cancer patients, but also within their family and oncology team, with the aim of improving compliance with anti­cancer therapies. Nurse-delivered, one-on-one sessions focusing on depression education, problem-solving, coping techniques, and telecare management of pain and depression also improves outcomes among depressed cancer patients.²⁰

Hospital-based inpatient and outpatient palliative care consultation teams are becoming more common. A randomized controlled trial of early palliative care outpatient consultation for patients with incurable lung cancer showed improved depression outcomes, better quality of life, and a modest improvement in survival.²¹ Although the most effective elements of a palliative care consult remain unspecified and require further research, improvement in outcomes may result from more effective symptom management, better acknowledgement of the burden of illness on the patient or family, or reduced need for hospitalization. Therefore, mental health professionals should consider palliative care consultation for advanced cancer patients with signs of psychological distress.

Pharmacotherapy options

Antidepressants. Patients with excessive guilt, anhedonia, hopelessness, or ruminative thinking along with a related impairment in quality of life may benefit from pharmacotherapy regardless of whether they meet diagnostic criteria for MDD. Although SSRIs and SNRIs have become a mainstay in managing depression, placebo-controlled trials have yielded mixed results in depressed cancer patients. Furthermore, differences in efficacy among these antidepressants may not be significant, according to a recent meta-analysis.²²

Select an antidepressant based on the patient’s past treatment response, target symptoms, and potential for adverse events. Mirtazapine has relatively few drug interactions; the side effects of sedation and weight gain may be welcome among patients with insomnia and impaired appetite.²³ Furthermore, mirtazapine is a 5-HT3 receptor antagonist,²⁴ which suggests it might act as an effective antiemetic.²⁵ Other SNRIs, such as venlafaxine and duloxetine, have demonstrated benefits in managing neuropathic pain in patients who do not have cancer.²⁶

Psychostimulants. Patients with a prognosis of days or weeks might not have enough time for an antidepressant to achieve full effect. Open prospective trials and pilot studies have shown that psychostimulants can improve cancer-related fatigue and quality of life while also augmenting the action of antidepressants.²⁷ Psychostimulants, such as methylphenidate, have been used for treating cancer-related fatigue and depressive symptoms in medically ill patients. Their rapid onset of action, coupled with minimal side effect profile, make them a good choice for seriously ill patients with significant neurovegetative symptoms of a depressive disorder. Note: Avoid psychostimulants in patients with delirium and use with caution in patients with heart disease.²⁸

Novel agents. A growing body of preclinical research suggests that glutamate may be involved in the pathophysiology of MDD. Ketamine modulates glutamate neurotransmission as an N-methyl-d-aspartate receptor antagonist. A recent evaluation of a single dose IV of ketamine in a placebo-controlled, double-blind trial found that depressed patients receiving ketamine experienced significant improvement their depressive symptoms.²⁹ Irwin and Iglewicz³⁰ describe 2 hospice patients administered a single oral dose of ketamine, which provided rapid relief of depressive symptoms and was well tolerated.

Transdermal selegiline may help patients who have trouble taking oral medications, including antidepressants. Inability to tolerate or absorb medications may be related to several conditions such as head and neck cancer, severe mucositis, and dysphagia. The dose-related dietary requirements—tyramine restriction—and careful monitoring for drug interactions may limit the use of selegiline in medically ill patients.³¹Table 3 features a list of dosing recommendations for pharmacotherapeutic options.³²

Use the strategy of “start low, go slow” when initiating and adjusting antidepressants because patients with cancer and other advanced illnesses often have concomitant organ failure and are at risk of drug interactions. Carefully review your patient’s medication list for agents that are no longer beneficial or possibly contributing to depressive symptoms to help reduce the risk of adverse pharmacokinetic and pharmaco-dynamic interactions.

Requests for a hastened death

As many as 8.5% of terminally ill patients have a sustained and pervasive wish for an early death.³³ Although requests for a hastened death may evoke strong emotional reactions and compel many clinicians to recoil or harshly reject such requests, consider such requests as an opportunity to gain insight into the patient’s narrative of his (her) suffering. The clinician’s role in such cases is to identify suicidality and perform a thorough suicide risk assessment. Interventions to prevent suicide should attempt to balance the seriousness of self-harm threats with restrictions on the patient’s liberty.³⁴

Clinicians also need to consider the patient’s prognosis in their decision-making. For example, an extremely depressed or suicidal patient may not benefit from psychiatric hospitalization if she (he) has progressive neurovegetative symptoms and a prognosis of only a few weeks to live. These situations often are challenging and require a careful, informed discussion of the risks and benefits of all proposed interventions.

Clinicians also should be familiar with distinctions among ethical issues in end-of-life care, including physician-assisted suicide, euthanasia, and palliative sedation (Table 4).^35,36

In Oregon, requests for physician-assisted suicide and hastened death through the state’s Death with Dignity Act often are short lived, and may not persist when clinicians offer patients good symptom management and psychological support.³⁷ Requests for a hastened death often are motivated by loss of control, inability to find meaning in death, indignity from being dependent, and concern for future suffering and burden on loved ones.³⁷

Carefully evaluate requests for hastened death in a manner that balances your personal and professional integrity. To preserve personal integrity, clearly communicate therapeutic interventions that you can and cannot provide. To ensure the patient does not feel abandoned, identify factors that contribute to the patient’s suffering and express a desire to search for alternative care approaches that will be mutually acceptable to the patient and to you.

Advance care planning and palliative care consultations may help in these circumstances. A randomized trial comparing advance care planning vs standard care in hospitalized geriatric patients found that advance care planning was more likely to lead to end-of-life wishes that were recognized by clinicians, and was associated with less distress, anxiety, and depression as reported by bereaved family members.³⁸

Clinicians can assist patients with advanced care planning by helping them fill out advance directives, such as durable health care power of attorney documents and a living will. Palliative care clinicians can offer specialty-level assistance in advance care planning, provide focused assessments of physical and psychosocial symptoms, develop appropriate clinical goals, and assist in coordinating individualized care plans for seriously ill patients.²

Bottom Line

Depression commonly is encountered in hospice and palliative care patients and is associated with morbidity and distress. Validated screening tools can help you distinguish major depressive disorder from depressive symptoms in this population. Several psychotherapeutic techniques have been shown to be beneficial. In addition to traditional antidepressants, psychostimulants or ketamine may help address acute depressive symptoms in patients who have days or weeks to live.

Related Resources

• American Academy of Hospice and Palliative Medicine. www.aahpm.org.
• Death with Dignity National Center. www.deathwithdignity.org.
• National Hospice and Palliative Care Organization. www.nhpco.org.
• Oregon Health Authority. Death with Dignity Act. http://public.health.oregon.gov/ProviderPartnerResources/Evaluationresearch/deathwithdignityact/Pages/index.aspx.

Drug Brand Names

Duloxetine • Cymbalta                        Modafinil • Provigil

Ketamine • Ketalar                             Selegiline (transdermal) • EMSAM

Methylphenidate  • Concerta, Ritalin     Mirtazipine • Remeron

Venlafaxine • Effexor                                    

Disclosures

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The demand for “legal highs”—intoxicating natural or synthetic substances that are not prohibited by law—continues to increase. Young adults may use these substances, which are widely available on the internet, at “head shops,” and at gas stations. Such substances frequently cause adverse medical and psychiatric effects, exemplified by recent reports concerning the dangers of using synthetic cannabinoids (eg, “Spice,” “K2”) and synthetic cathinones (“bath salts”). Although these 2 substances now are illegal in many jurisdictions, other novel substances of misuse remain legal and widely available, including Kratom and methoxetamine.

Because these substances usually are not detectable on standard urine toxicology screens, clinicians need to be aware of them to be able to take an accurate substance use history, consider possible dangerous interactions with prescribed psychotropics, and address medical and psychiatric complications.

Kratom is an herbal product derived from Mitragyna speciosa, a plant native to Southeast Asia. Traditionally used as a medicinal herb, it increasingly is being used for recreational purposes and remains legal and widely available in the United States. Kratom’s leaves contain multiple alkaloids, including mitragynine and 7-hydroxymitragynine, which are believed to act as agonists at the μ-opioid receptor. Mitragynine also may have agonist activity at post-synaptic 
α2-adrenergic receptors, as well as antagonist activity at 5-HT2A receptors.¹ Mitragynine is 13 times more potent than morphine, and 7-hydroxymitragynine is 4 times more potent than mitragynine.²

Kratom is available as leaves, powdered leaves, or gum. It can be smoked, brewed into tea, or mixed with liquid and ingested. Effects are dose-dependent; lower doses tend to produce a stimulant effect and higher doses produce an opioid effect. A typical dose is 1 to 8 g.³ Users may take Kratom to experience euphoria or analgesia, or to self-treat opioid withdrawal symptoms.³ Kratom withdrawal syndrome shares many features of classic opioid withdrawal—diarrhea, rhinorrhea, cravings, anxiety, tremor, myalgia, sweating, and irritability—but has been reported to be less severe and shorter-lasting.¹ Kratom withdrawal, like opioid withdrawal, may respond to supportive care in combination with opioid-replacement therapy. Airway management and naloxone treatment may be needed on an emergent basis if a user develops respiratory depression.² There have been case reports of seizures occurring following Kratom use.²

Methoxetamine is a ketamine analog originally developed as an alternative to ketamine. It isn’t classified as a controlled substance in the United States and is available on the internet.² Methoxetamine is a white powder typically snorted or taken sublingually, although it can be injected intramuscularly. Because methoxetamine’s structure is similar to ketamine, its mechanism of action is assumed to involve glutamate N-methyl-d-aspartate receptor antagonism and dopamine reuptake inhibition. Doses range from 20 to 100 mg orally and 10 to 50 mg when injected. Effects may not be apparent for 30 to 90 minutes after the drug is snorted, which may cause users to take another dose or ingest a different substance, possibly leading to synergistic adverse effects. Effects may emerge within 5 minutes when injected. The duration of effect generally is 5 to 7 hours—notably longer than ketamine—but as little as 1 hour when injected.

No clinical human or animal studies have been conducted on methoxetamine, which makes it difficult to ascertain the drug’s true clinical and toxic effects; instead, these effects must be surmised from user reports and case studies. Desired effects described by users are similar to those of ketamine: dissociation, short-term mood elevation, visual hallucinations, and alteration of sensory experiences. Reported adverse effects include catatonia, confusion, agitation, and depression.⁴ In addition, methoxetamine may induce sympathomimetic toxicity as evidenced by tachycardia and hypertension. Researchers have suggested that patients who experience methoxetamine toxicity and require emergency treatment be managed with supportive care and benzodiazepines.⁵

Staying current is key

New and potentially dangerous substances are being produced so quickly distributors are able to stay ahead of regulatory efforts. When one substance is declared illegal, another related substance quickly is available to take its place. To provide the best care for our patients, it is essential for psychiatrists to stay up-to-date about these novel substances.

Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

The demand for “legal highs”—intoxicating natural or synthetic substances that are not prohibited by law—continues to increase. Young adults may use these substances, which are widely available on the internet, at “head shops,” and at gas stations. Such substances frequently cause adverse medical and psychiatric effects, exemplified by recent reports concerning the dangers of using synthetic cannabinoids (eg, “Spice,” “K2”) and synthetic cathinones (“bath salts”). Although these 2 substances now are illegal in many jurisdictions, other novel substances of misuse remain legal and widely available, including Kratom and methoxetamine.

Because these substances usually are not detectable on standard urine toxicology screens, clinicians need to be aware of them to be able to take an accurate substance use history, consider possible dangerous interactions with prescribed psychotropics, and address medical and psychiatric complications.

Kratom is an herbal product derived from Mitragyna speciosa, a plant native to Southeast Asia. Traditionally used as a medicinal herb, it increasingly is being used for recreational purposes and remains legal and widely available in the United States. Kratom’s leaves contain multiple alkaloids, including mitragynine and 7-hydroxymitragynine, which are believed to act as agonists at the μ-opioid receptor. Mitragynine also may have agonist activity at post-synaptic 
α2-adrenergic receptors, as well as antagonist activity at 5-HT2A receptors.¹ Mitragynine is 13 times more potent than morphine, and 7-hydroxymitragynine is 4 times more potent than mitragynine.²

Kratom is available as leaves, powdered leaves, or gum. It can be smoked, brewed into tea, or mixed with liquid and ingested. Effects are dose-dependent; lower doses tend to produce a stimulant effect and higher doses produce an opioid effect. A typical dose is 1 to 8 g.³ Users may take Kratom to experience euphoria or analgesia, or to self-treat opioid withdrawal symptoms.³ Kratom withdrawal syndrome shares many features of classic opioid withdrawal—diarrhea, rhinorrhea, cravings, anxiety, tremor, myalgia, sweating, and irritability—but has been reported to be less severe and shorter-lasting.¹ Kratom withdrawal, like opioid withdrawal, may respond to supportive care in combination with opioid-replacement therapy. Airway management and naloxone treatment may be needed on an emergent basis if a user develops respiratory depression.² There have been case reports of seizures occurring following Kratom use.²

Methoxetamine is a ketamine analog originally developed as an alternative to ketamine. It isn’t classified as a controlled substance in the United States and is available on the internet.² Methoxetamine is a white powder typically snorted or taken sublingually, although it can be injected intramuscularly. Because methoxetamine’s structure is similar to ketamine, its mechanism of action is assumed to involve glutamate N-methyl-d-aspartate receptor antagonism and dopamine reuptake inhibition. Doses range from 20 to 100 mg orally and 10 to 50 mg when injected. Effects may not be apparent for 30 to 90 minutes after the drug is snorted, which may cause users to take another dose or ingest a different substance, possibly leading to synergistic adverse effects. Effects may emerge within 5 minutes when injected. The duration of effect generally is 5 to 7 hours—notably longer than ketamine—but as little as 1 hour when injected.

No clinical human or animal studies have been conducted on methoxetamine, which makes it difficult to ascertain the drug’s true clinical and toxic effects; instead, these effects must be surmised from user reports and case studies. Desired effects described by users are similar to those of ketamine: dissociation, short-term mood elevation, visual hallucinations, and alteration of sensory experiences. Reported adverse effects include catatonia, confusion, agitation, and depression.⁴ In addition, methoxetamine may induce sympathomimetic toxicity as evidenced by tachycardia and hypertension. Researchers have suggested that patients who experience methoxetamine toxicity and require emergency treatment be managed with supportive care and benzodiazepines.⁵

Staying current is key

New and potentially dangerous substances are being produced so quickly distributors are able to stay ahead of regulatory efforts. When one substance is declared illegal, another related substance quickly is available to take its place. To provide the best care for our patients, it is essential for psychiatrists to stay up-to-date about these novel substances.

Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

The demand for “legal highs”—intoxicating natural or synthetic substances that are not prohibited by law—continues to increase. Young adults may use these substances, which are widely available on the internet, at “head shops,” and at gas stations. Such substances frequently cause adverse medical and psychiatric effects, exemplified by recent reports concerning the dangers of using synthetic cannabinoids (eg, “Spice,” “K2”) and synthetic cathinones (“bath salts”). Although these 2 substances now are illegal in many jurisdictions, other novel substances of misuse remain legal and widely available, including Kratom and methoxetamine.

Because these substances usually are not detectable on standard urine toxicology screens, clinicians need to be aware of them to be able to take an accurate substance use history, consider possible dangerous interactions with prescribed psychotropics, and address medical and psychiatric complications.

Kratom is an herbal product derived from Mitragyna speciosa, a plant native to Southeast Asia. Traditionally used as a medicinal herb, it increasingly is being used for recreational purposes and remains legal and widely available in the United States. Kratom’s leaves contain multiple alkaloids, including mitragynine and 7-hydroxymitragynine, which are believed to act as agonists at the μ-opioid receptor. Mitragynine also may have agonist activity at post-synaptic 
α2-adrenergic receptors, as well as antagonist activity at 5-HT2A receptors.¹ Mitragynine is 13 times more potent than morphine, and 7-hydroxymitragynine is 4 times more potent than mitragynine.²

Kratom is available as leaves, powdered leaves, or gum. It can be smoked, brewed into tea, or mixed with liquid and ingested. Effects are dose-dependent; lower doses tend to produce a stimulant effect and higher doses produce an opioid effect. A typical dose is 1 to 8 g.³ Users may take Kratom to experience euphoria or analgesia, or to self-treat opioid withdrawal symptoms.³ Kratom withdrawal syndrome shares many features of classic opioid withdrawal—diarrhea, rhinorrhea, cravings, anxiety, tremor, myalgia, sweating, and irritability—but has been reported to be less severe and shorter-lasting.¹ Kratom withdrawal, like opioid withdrawal, may respond to supportive care in combination with opioid-replacement therapy. Airway management and naloxone treatment may be needed on an emergent basis if a user develops respiratory depression.² There have been case reports of seizures occurring following Kratom use.²

Methoxetamine is a ketamine analog originally developed as an alternative to ketamine. It isn’t classified as a controlled substance in the United States and is available on the internet.² Methoxetamine is a white powder typically snorted or taken sublingually, although it can be injected intramuscularly. Because methoxetamine’s structure is similar to ketamine, its mechanism of action is assumed to involve glutamate N-methyl-d-aspartate receptor antagonism and dopamine reuptake inhibition. Doses range from 20 to 100 mg orally and 10 to 50 mg when injected. Effects may not be apparent for 30 to 90 minutes after the drug is snorted, which may cause users to take another dose or ingest a different substance, possibly leading to synergistic adverse effects. Effects may emerge within 5 minutes when injected. The duration of effect generally is 5 to 7 hours—notably longer than ketamine—but as little as 1 hour when injected.

No clinical human or animal studies have been conducted on methoxetamine, which makes it difficult to ascertain the drug’s true clinical and toxic effects; instead, these effects must be surmised from user reports and case studies. Desired effects described by users are similar to those of ketamine: dissociation, short-term mood elevation, visual hallucinations, and alteration of sensory experiences. Reported adverse effects include catatonia, confusion, agitation, and depression.⁴ In addition, methoxetamine may induce sympathomimetic toxicity as evidenced by tachycardia and hypertension. Researchers have suggested that patients who experience methoxetamine toxicity and require emergency treatment be managed with supportive care and benzodiazepines.⁵

Staying current is key

New and potentially dangerous substances are being produced so quickly distributors are able to stay ahead of regulatory efforts. When one substance is declared illegal, another related substance quickly is available to take its place. To provide the best care for our patients, it is essential for psychiatrists to stay up-to-date about these novel substances.

Disclosure
Dr. Troy reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.