Psycho-Oncologyand Palliative Care: Potential Contributions :Psycho-Oncologyand Palliative Care: Potential Contributions Jimmie C. Holland, M.D. Founding President, International Psycho-Oncology Society Attending Psychiatrist, Psychiatry& Behavioral Sciences Memorial Sloan-Kettering Cancer Center


PSYCHO-ONCOLOGY Definition :PSYCHO-ONCOLOGY Definition Multidisciplinary subspecialty of oncology concerned with the emotional responses of patients at all stages of disease, their families and staff (psychosocial) The psychological, social and behavioral variables that influence cancer prevention, risk and survival (cancer control)


HISTORICAL BARRIERS – 1 :HISTORICAL BARRIERS – 1 Double Stigma Patients not told their diagnosis and psychological responses could not be explored Mental disorders/illness long feared and stigmatized


HISTORICAL BARRIERS – 2 :HISTORICAL BARRIERS – 2 Belief that subjective phenomena (pain, feelings) could not be quantitatively measured Patient’s self-report was considered unreliable (only observer ratings reliable) Social science methods were not understood by basic scientists


Basic to Psycho-Oncology Research :Basic to Psycho-Oncology Research Developed and validated quantitative measures of subjective symptoms QOL Core and disease specific modules Pain Fatigue Distress Anxiety Depression Delirium


Barriers to Psych-Oncology Issues in Palliative Care :Barriers to Psych-Oncology Issues in Palliative Care Attitudes of medical staff that assume the “nonphysical” psychological domain as less important Attitudes of patients and family: “Think I’m crazy”: embarrassed, angry by mental health consultation Attitudes may discourage integration of mental health member of palliative care team


Slide 7:Absence of training of palliative care team in recognition, diagnosis and management of distress and absence of an algorithm when to refer to mental health Inadequate funding for mental health counselors as compared to medical Absence of minimum standards and accountability for psychological, social care and for meeting existential, spiritual needs Barriers to Psych-Oncology Issues in Palliative Care


Slide 8:Inadequate numbers of well-trained mental health professionals in psychosocial care Too few training programs Absence of oversight of staff in management of psychosocial/ psychiatric problems Barriers to Psych-Oncology Issues in Palliative Care


Slide 9:Physical symptoms (pain, fatigue) Psychological (fears, sadness) Social (family, future) Spiritual – seeking a comforting philosophical, religious, or spiritual beliefs Existential – seeking meaning of life in the face of death Advanced Cancer RequiresCoping With


EXISTENTIAL CRISES IN CANCER :EXISTENTIAL CRISES IN CANCER Adapted from McCormick & Conley, 1995 “I could die from this.” “I have survived -- will it Return?” “I will likely die” -- depressed; anxious “I am dying.”


Slide 11:“We are not ourselves when nature, being oppressed, commands the mind to suffer with the body” King Lear, Act II, Sc. IV, L 116-119


Slide 12:What to call this constellation of non physical aspects of severe illness? “Suffering of the mind” “Existential crisis” “Human side” Overlapping psychological and spiritual domains: psychospiritual crisis


Slide 13:Loss of meaning Loss of control (helpless) Need for connection to some larger whole, greater than self J. Kass, 1996 Psychospiritual Crisis of ILLNESS


Slide 14:A way of coping and feeling in control despite the uncertainty, treat of death, the unknown, and loss A set of moral values Comforting rituals (prayer, mediation) An existential perspective (meaning of life, death, connection to greater whole) Support (emotional and tangible) of those who share similar beliefs Spiritual and ReligiousBeliefs Provide


DISTRESS in Cancer :DISTRESS in Cancer An unpleasant emotional experience of a psychological, social and/or spiritual nature which extends on a continuum from normal feelings of vulnerability, sadness and fears to disabling problems such as depression, anxiety, panic, social isolation and spiritual crisis. Adapted, NCCN


Contributions to Care - 1 :Contributions to Care - 1 Psychological interventions unique for palliative care Meaning-centered therapies ? Frankl Meaning-Based Breitbart ? Dignity-Conserving Chochinov ? Meaning-Folkman Holland


Slide 17:Help patient reconcile life goals and plans with constraints of illness and loss Use beliefs, values, prior strengths, to find a new and tolerable meaning of life in the face of death Folkman-based Psychotherapy


Contributions to Care - 2 :Contributions to Care - 2 Concern for family members ? Identifying their concerns Conflict, needs (distress levels are as high as patients) ? Evaluation of minor children-guidance in how to talk to them ? Grief counseling for family


Contributions to Care - 3 :Contributions to Care - 3 Education of staff and patients that seeking treatment for psychological problems is not a sign of weakness Advocate as a team member to psychosocial and “human” side of care


Treatment Guidelines for Mental Health Professionals :Treatment Guidelines for Mental Health Professionals DSM-IV Diagnoses Dementia Delirium Mood disorder (depression) Adjustment disorder (reactive anxiety/depression) Anxiety disorder Substance abuse Personality disorder


Treatment Guidelines for Social Work :Treatment Guidelines for Social Work Practical Problems housing, assistance Psychosocial Problems family conflict communication culture/language


Treatment Guidelines for Pastoral Counseling :Treatment Guidelines for Pastoral Counseling Death/afterlife Loss of faith/meaning Grief Isolation from religious community Guilt Hopelessness


Slide 23:NCCN Clinical Practice Guidelines for distress have been modified for end-of- life care – they should be tested in a clinical setting Holland & Chertkov, 2001 IOM Improving Palliative-Care


Contributions to Care – Burnout :Contributions to Care – Burnout Mental health of Staff Physicians’ acknowledged feelings (anger, frustration, depression) Affect Clinical decisions Behavior with patients Quality of care Risk of burnout Meier et al, 2002


Common Burnout Symptoms :Common Burnout Symptoms PSYCHOLOGICAL Frustration Irritability Tense, sad feeling Anger Withdrawn; “Numb” Detached emotionally Cynical about work PHYSICAL Fatigue Insomnia Headaches Back aches Appetite change GI disturbance


UK Study 476 Oncologists :UK Study 476 Oncologists Burnout Emotional exhaustion 31% Low personal Accomplish 33% Diminished Empathy 23% Psychiatric Disorder (GHI) 28% Ramirez et al, BMJ, 1995


Research Directions - 1 :Research Directions - 1 Pro inflammatory cytokines as cause for fatigue, poor concentration, depression, anxiety (? in pancreatic patients)


Slide 29:Cytokine-induced Sickness behavior in animals Several cancer-related symptoms Fatigue Pain Anxiety Depression Cognitive loss Weakness Research Directions - 2


Slide 30:C. Cleeland, et al, Cancer, 2003, Working Group Research Directions - 3


Research Directions - 4 :Research Directions - 4 Genetic contributions to chemo- related cognitive deficit APOE4 allele Fatigue (DYPD over expression)


Slide 32:“….the secret of the care of the patient is in caring for the patient.” Peabody, JAMA 1926


Slide 33:IPOS Liaison to National Psycho-Oncology Societies hollandj@mskcc.org www.apos-society.org


Slide 34:8th WORLD CONGRESS PSYCHO-ONCOLOGY "Multidisciplinary Psychosocial Oncology: Dialogue and Interaction" 18 - 21 October 2006 Palazzo del Cinema Venice, Italy Details will continue to be posted on the conference website at www.ipos2006.it