What are the broad issues around mental health in advanced cancer?

1. What are the broad issues around mental health in advanced cancer? Practical approaches to mental health issues in palliative care Practice Forum DoH 2012 Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

2. Outline 1 • Mental health and mental ill-health • ‘normalisation’ • The INDIVIDUAL and the cancer trajectory • Complexity • Depletion • ‘Diagnosis’ – need for a TRULY holistic framework Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

3. Outline 2 8. Organizational contributions to distress 9. Mental health of staff 10. Challenging mental health issues • Underlying personality disorder • Families (who carry their own history) • Drug and alcohol issues • Intellectual disability, autism • ‘serious’ mental illness • Schizophrenia, schizoaffective disorder, bipolar affective disorder Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

4. Outline 3 11. Education and training 12. Translation of clinical research into practice Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

5. Mental health and mental illness - 1 • Preventative, preservative Early intervention, facilitation of adjustment, enhancing coping style, communication skills, paced information, social supports Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

6. Mental health and mental illness - 2 2. Reactive (psychiatric morbidity consequent upon diagnosis, disease course, treatments) • identification of high risk groups • screening • prompt treatment Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

7. Mental health and mental illness - 3 3. Underlying psychiatric disorder (schizophrenia, schizoaffective disorder, bipolar affective disorder – but also OCD, eating disorders) • access, collaborative care, adherence to treatment, perception of competence, social resources Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

8. Anxiety • ubiquitous • strategies +/- medication • extremely distressing • treat like pain Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

9. Depression • >25%, increasing with advancing disease • Under-recognized, under-rated, un-treated / under-treated • Amplifies distressing symptoms (pain) • Different use of antidepressants in PC – matching receptor profile with desired effect • Psychostimulants • Research implications Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

10. Post-trauma syndromes Arising from the experience of life-threatening disease or its treatment Reactivation of previous trauma in setting of dependence, helplessness, fear, threat to life Can emerge in delirium Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

11. Delirium High prevalence Multifactorial Concept of ‘deliriant threshold’ Life-threatening Highly distressing Nursing nightmare Hypoactive delirium missed Misdiagnosis Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

12. Other organic mental states 1º cerebral tumour 2º cerebral metastases Leptomeningeal infiltration Limbic encephalitis Paraneoplastic syndromes Hepatic encephalopathy Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

13. ‘Normalization’ Take care with using this counselling approach in a cancer setting; may be experienced as out of touch, even patronizing Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

14. The individual and the cancer trajectory What is the life story of the person who develops cancer? Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

15. Death Palliative care Palliative care

16. Death Palliative care age, developmental stage, IQ, gender, sexuality, strengths, vulnerabilities, personality, attachments, losses, previous trauma, social supports, culture, religion, spiritual beliefs, past psychiatric disorder, substance use, comorbidities UNIQUENESS Palliative care

17. Complexity heterogeneity of cancer population in palliative care (cf spinal unit, cardiac unit) complex needs MDT RCTs difficult to mount ‘rational’ individual tailoring of treatments Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

18. Depletion A product of prolonged stress and fear, toxic treatments, sub-optimal nutrition, reduced exercise or mobility, existential anguish, altered relationships to self and others, multiple losses…… A useful concept when explaining that, just as the body is depleted and fatigued, so is the brain Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

19. Diagnosis ‘knowing through’ – discerning, distinguishing – not limited to disease requires knowledge of patient’s underlying disease and treatment effects; past trauma, attachment style, losses, personality, coping strategies, psychiatric illness; social supports; IQ cultural influences; spiritual beliefs need to know context and time-frame Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

20. “this patient won’t communicate with us” Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

22. What is going on here? Angry Depressed (especially agitated depression) Paranoid Delirious (hyperactive) Demented Cerebral pathology Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

24. What’s going on here? Depressed Demoralized Conservation-withdrawal Given-up Over-sedation Delirium (hypoactive) Sensory impairment (blind, deaf) Unable to speak Dying Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

25. Organizational contributions to distress Delays Lack of continuity Poor communication Poor leadership Poor staff cohesion Lack of pathway co-ordination Unconscious acts that diminish dignity Random acts of kindness Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

26. Staff health Compassion fatigue, burnout Dysfunctional teams – rampant splitting Reflective practice Supervision Self care Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

27. Challenging mental health issues • 1. Personality disorder • esp borderline, narcissistic, paranoid • traits may be accentuated where dependency, attachment, trust issues paramount • can create havoc in team functioning • early recognition and staff support important Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

28. Challenging mental health issues • 2. Families • Dysfunctional, disengaged, enmeshed, members with own agendas, members out of phase with the process, • May have several personality disorders in one family!! • Toll on staff • Caring for the family an extension of patient care – ripple effect • Family caregiver guidelines Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

29. Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

30. Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

31. Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

32. Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

33. Challenging mental health issues • 3 Drug and alcohol issues • Perjorative attitudes • Alcohol and drug abuse often not screened for • Tendency to withhold opiates for fear of worsening addiction – but higher tolerance • Fear of marketing drugs • Comorbid medical, social and forensic Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

34. Challenging mental health issues • 4. Intellectual disability and autism spectrum • Therapeutic alliance • Communication of distress • Case-manager, secondary consultation, in-service training Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

35. Challenging mental health issues • 5. Persistent serious mental illness • Bilateral ignorance of each other’s principles and methods of care: PC/MH • Fear of death and dying (MH) • Discomfort with opiates (MH) • Fear of mental illness (PC) • Lack of skills in handling disturbed patients (PC) • However many features in common Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

36. Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

37. Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

38. Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

39. Education and training Psychosocial skills in cancer care a specialist area The biological perspectives should always be considered Different disciplines, different roles need different skills training Professional development courses Proposed degree courses Statewide remit Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

40. Translational research Designing studies that have clinical relevance Qualitative studies as well as quantitative studies The collaborative initiatives The VCCC Guidelines review and implementation Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital

41. Thank you! Questions? Dr Di Clifton, Psychiatrist, Medical Director Psychosocial Cancer Care St V's Hospital