TCPR: Dr. Breitbart, please tell us the unique role psychiatry plays in palliative care.
Dr. Breitbart: The goals of palliative care are to provide physical symptom control throughout the entire course of an illness, from the diagnosis of a life-threatening illness all the way through the advanced stages and the last periods of life, and to follow families through the bereavement process. Psychiatric palliative care helps to expand that focus beyond pain and physical symptom control to include other aspects of quality of life, such as the psychiatric, psychosocial, existential, and spiritual aspects of palliative care. These may ultimately culminate for some patients in being able to have a peaceful acceptance of death or acceptance of the life that they lived so that they can face death with peace.
TCPR: What are some of the concerns that lead to psychiatric consultation in the palliative care setting?
Dr. Breitbart: There are basically three categories of problems that warrant attention from a psychiatrist. One is the psychiatric and psychological disorders that occur as comorbid disorders in people with physical illnesses. The second is symptom clusters that we have expertise as psychiatrists addressing. And then the third is existential distress that is so common in all of us.
TCPR: Let’s start with these psychiatric comorbidities. What specific challenges do you encounter when people have psychiatric complaints in the context of medical illnesses?
Dr. Breitbart: Anxiety is one of the most challenging complaints. If you do a survey of the various symptoms that patients experience with cancer or HIV disease, for instance, anxiety is up there—in the 80% to 90% range (Breitbart W & Alici Y, Harv Rev Psychiatry 2009;17:361–376). The real challenge in the medical setting is trying to determine in fact whether we’re seeing anxiety related to a psychiatric source or anxiety from a medical source. For instance, it is quite common to see patients get anxious when experiencing a pulmonary embolism. Some of the medications that are used to treat nausea can also cause akathisia and severe anxiety.
TCPR: Etiology is probably an important consideration in depression, too?
Dr. Breitbart: The challenges in depression are actually a bit more complex because the DSM-IV criteria for a diagnosis of depression were established in physically healthy patients. For the last 20 or so years, those of us in the psychosomatic medicine world have been trying to extrapolate those criteria to help us make diagnoses of clinical depression in a physically ill population. There are many symptoms of clinical depression that can be produced by, for instance, cancer or its treatment. It is very difficult to make a diagnosis of depression with any kind of specificity when, for instance, symptoms of appetite loss, weight loss, feelings of hopelessness, psychomotor retardation, and others can be caused by the illness or the treatment itself.
TCPR: How do you address this?
Dr. Breitbart: There are a number of ways that we have been trying to deal with that problem over the years. We have experimented with the use of a set of substitution criteria—something called the “Endicott Substitution Criteria” that replace nonphysical symptoms for some of the physical symptoms of depression. Another very convenient method that has been developed over the last 10 years is what we call an “increased threshold approach” to diagnosing depression in the cancer population or advanced illness population. Instead of requiring the main threshold criteria symptom of depressed mood for a couple of weeks or more, plus four more symptoms (for a total of five), we just increase the threshold to seven. The thresholds for depression or anhedonia plus six more symptoms, and that pretty much correlates with the specificity of diagnosing clinical depression that you would get with using the Endicott substitution criteria. Another issue is that it is sometimes difficult to determine whether someone is having a major depressive episode that is essentially the same type of disorder that one would see in a physically health person, or if it is caused by medical etiologies. In other words, the progression of cancer itself can lead to depression.
TCPR: Does this make a difference in treatment?
Dr. Breitbart: Fortunately, many of the treatments are quite similar in terms of the psychotherapy and the psychopharmacologic interventions. There have been about a dozen trials of traditional antidepressants that show that even in terminally ill and advanced cancer populations, those medications work regardless of etiology (Rhondali W et al, Eur J Hosp Pharm 2012;19(1):41–44).
TCPR: Delirium is a big concern in palliative care. Please tell us about that.
Dr. Breitbart: Delirium is a primary focus of psychiatric intervention and care, particularly in the hospital or in the hospice palliative care unit setting. For comparison, the prevalence of depression is somewhere in the range of 15% to 25% in the palliative care setting, while the prevalence of delirium, particularly in the last weeks of life, may rise as high as 85% (Breitbart W & Alici Y, JAMA 2008;300(24):2898–2910). The challenges are in terms of the goals of care. Most of the time when we treat delirium, we hope to achieve a state in which patients are awake and alert and able to communicate with their physician and the family. When patients are dying that goal may not be achievable, so we are often faced with a dilemma: do I keep a patient somewhat awake but distressed and hallucinating; or do I work with the patient and the family to keep that patient comfortable, but perhaps a bit sleepy or sedated?
TCPR: When you’re treating patients with delirium at the end of life, what types of treatments might you give or withhold?
Dr. Breitbart: The principles for managing delirium are the same no matter what the stage. You want to approach delirium by doing two things at the same time: You want to try to identify and treat or remove the sources, and you want to control the symptoms of delirium, which is sometimes done with antipsychotic drugs. However, when delirium appears in the last weeks of life, you may decide that you do not want to be as aggressive as you would in someone who is, for instance, getting a bone marrow transplant or has a fever or sepsis and is delirious. But you can still use psychopharmacologic interventions to try to control the symptoms, and most of the time you will be able to achieve the goal of the patient being somewhat awake and alert and able to communicate.
TCPR: Can you speak about the subtypes of delirium?
Dr. Breitbart: Despite the fact that delirium can be categorized into various subtypes based on things like motoric function or arousal disturbance, only about half of patients with delirium have what is called an agitated, hyperactive, or hyperaroused delirium (what most people think of when they hear “delirium”). About 50% of patients with delirium in the medical setting, and particularly in the palliative care setting, have hypoaroused or “quiet” delirium. However, this population is as distressed as the hyperactive, hyperaroused, or agitated delirium patients (Breitbart et al, Psychosomatics 2002;43(3)183–194). We have been able to show with studies of antipsychotic interventions that those patients respond just as well to treatment as the hyperactive or agitated delirious patients.
TCPR: Please tell us about concerns like fear of death, the meaning of life, and other existential concerns and distress. How do we help patients facing the end of life deal with these?
Dr. Breitbart: We have started to move away from the notion that all existential and spiritual concerns about death and being able to look back and accept the life that one has lived are purely the domain of the chaplain or the clergy in palliative care. Certainly, if someone is having a crisis of religious faith, involving a chaplain or clergy is reasonable. But most patients are not having these crises of religious faith; what they are having is a crisis of meaning in their life that is caused by not being able to complete their life trajectory. So when we think of spirituality in our clinical research group we think it has components of both religious faith and of personal meaning. So we deal with spiritual or existential concerns and stress in patients by focusing on concepts such as meaning and purpose, and by helping patients come to some sense of coherence about the meaning in their lives, leaving a legacy.
TCPR: This relates to the idea of dying with dignity?
Dr. Breitbart: Yes, there are now about three or four clinical interventions that focus on meaning, dignity, or end of life task completion. There is meaning-centered psychotherapy from our group, dignity-conserving therapy from a group led by Harvey Chochinov from Canada, and end of life task completion work developed by Karen Steinhauser from Duke. David Kissane in Australia developed something called cognitive existential therapy, focused on cognitive distortion and dealing with existential issues. Probably the granddaddy of all of these interventions was David Spiegel’s supportive expressive psychotherapy in women with advanced breast cancer where they not only provided support, but focused on detoxifying death.
TCPR: Very interesting. Are these therapies evidence-based?
Dr. Breitbart: There are multiple interventions that have been developed and tested in randomized controlled trials and are now tools that palliative care physicians, psychiatrists, psychologists, social workers, and other mental health professionals in palliative care settings can apply to help patients deal with concerns of profound loss of meaning, demoralization, end of life task completion, leaving a legacy, conserving dignity, being able to live until they die, and being able to deal with what lies beyond. Many of these interventions—meaning-centered psychotherapy in particular—have been shown to help maintain sense of meaning, hope, and lessen the fear of death (Breitbart W et al, Psycho-Oncology 2010;19(1):21–28; Breitbart W et al, J Clin Oncology 2012;30(12):1304–1309). We just finished the second edition of the Oxford Handbook of Psychiatry and Palliative Medicine that is now in paperback, and it really covers every aspect of psychiatric palliative care from diagnosis to assessment to some of these psychotherapies.
TCPR: Can you briefly comment on the role of the psychiatrist in alleviating the suffering of caregivers, like family members, nursing staff, and others?
Dr. Breitbart: We have learned from the caregiver literature that caregivers are extraordinarily distressed and have high rates of comorbid psychiatric disorders. There are a lot of practical concerns: financial impact of caregiving, physical exhaustion, skills they are not prepared for that they need to suddenly learn related to nursing, and so forth. We are developing a caregivers program in our Department of Psychiatry at Sloan-Kettering that focuses on the needs of caregivers and family members. We also have a family therapy program and a couples program under the umbrella of a caregiver program. We provide one-to-one caregiver intervention as well, which often moves into a bereavement phase. And we are developing an adaptation of psychotherapy for caregivers to help them deal with the burden of caregiving by focusing on the enhancement of meaning in their lives through the caregiving act. I think one would look to the caregiver literature for patients with Alzheimer’s disease and dementia as an example as the first population in which the problems of caregivers have been identified and interventions for caregivers have been developed. And we are catching up, but there are some unique aspects to this type of distress and caregiving burden in the palliative care setting as well.
TCPR: Thank you, Dr. Breitbart.