MENTAL HEALTH ISSUES IN PALLIATIVE CARE PATIENTS

may be reversedcontrolledunderstood

MENTAL HEALTH ISSUES IN PALLIATIVE CARE

UNDERSTANDING AND RESPONDING WITH SENSITIVITY

Terry Magee,

THE MYTHS OF MENTAL ILLNESS

LabelsMad Bad or Sad?Incapable IncompetentVulnerableWeakHysterical (esp. women)Attention seeking Potty, Bonkers, Nutty,DaftEccentric.IncurableNervyArtistic temperamentPandora's boxA Magical shaman or guru

MENTAL ILLNESS NATURE OR NURTURE?

DEPRESSION AND ANXIETY IN PALLIATIVE CARE

Depression and Anxiety are common in all patients with serious illness.They impact upon the psychosocial profile of the patient.They are often responsive to treatment .But a lack of attention to them may lead to ongoing dysphoria ( a disorder of affect characterised by depression and anguish)family conflictnon compliance with treatment increased length of hospitalisation persistent worry suicidal ideation

needless suffering

DEPRESSION

• What is it that becomes depressed ? might it be anger ?

• Is it because of our Genes?

• Is it a reaction to stress?

• Is it a chemical imbalance? (hormones or serotonin)

• Is it a result of our environment and socialisation?

• Is it our unconscious reacting to early childhood trauma or faulty parenting?

SYMPTOMS INDICATING DEPRESSIVE DISORDER IN THE

MEDICALLY ILL • Enduring depressed or sad mood, tearful

• Marked disinterest or lack of pleasure in social activities, family, and friends

• Feelings of worthlessness and hopelessness

• Excessive enduring guilt that illness is a punishment

• Significant weight loss or gain not explained by dieting, illness, or treatments.

• Hopeless about the future

• Enduring fatigue

• Increase or decrease in sleep not explained by illness or treatment

• Recurring thoughts of death or suicidal thoughts or acts

• Diminished ability to think and make decisions

INTERVENTIONS TO ASSIST THE DEPRESSED PATIENT

COMPLEMENTARY THERAPIES

• Guided imagery and visualisation• Aromatherapy and massage• Art and music therapy• Aerobic exercise• Life revue, life story and reminiscence therapy• Humour• Dance and movement therapy• Progressive somatic relaxation and biofeedback

INTERVENTIONS TO ASSIST THE DEPRESSED PATIENT

COGNITIVE INTERVENTIONSHelp the patient to identify and reality test

Self defeating assumptions

Negative automatic thoughts

Rumination on failure

Ability to set and achieve goals

Ability to determine realistic expectations

Teach “stop think strategy”Assist to accomplish personal enhancement activity

Avoid denying the patient’s sadness

Avoid chastising the patient for feeling low

Minarik (1996)

INTERVENTIONS TO ASSIST THE DEPRESSED PATIENT

INTERPERSONAL

• Enhance social skills through modelling, role play, feedback and positive reinforcement

• Build rapport with frequent short conversations, exchanges and connectedness

• Give attention even when the patient is withdrawn

• Mobilise family creative and social support networks

• Encourage open communication about feelings

• Teach the family how they can help

• Allow the patient time and space for reflection and reverie

Minarik (1996)

INTERVENTIONS TO ASSIST THE DEPRESSED PATIENT

BEHAVIOURAL• Provide directed activities• Use graded task assignment hierarchy• Develop daily activity schedule• Encourage the patient to keep a journal of successful

actions and revue• Use systematic application of reinforcement• Encourage self monitoring of predetermined behaviours

such as sleep pattern, diet and physical exercise• Focus on goal attainment and adaptive coping

SYMPTOMS INDICATING ANXIETY DISORDER IN THE MEDICALLY ILL• Chronic apprehension, worry, inability to relax which is not related to

illness or treatment• Difficulty in concentrating• Irritability or outbursts of anger• Difficulty falling asleep or staying asleep• Trembling or shaking• Exaggerated startle response• Perspiring for no obvious reason• Chest pain and shortness of breath unrelated to medical condition• Extreme fear of places, events, certain activities.• Recurring and persistent ideas, thoughts or impulses• Repetitive behaviours to prevent discomfort• Fear or “going crazy”• Exaggerated fear of dying

Barraclough (1997)

INTERVENTIONS TO ASSIST THE ANXIOUS PATIENT

LEVEL 1 PREVENTION

• Provide concrete objective information

• Ensure stressful event warning

• Increase opportunity for control

• Increase patient and family participation in care activity

• Openly acknowledge fears

• Explore near miss events

• Control symptoms

• Structure uncertainty

• Limit sensory deprivation and isolation

• Encourage hope

INTERVENTIONS TO ASSIST THE ANXIOUS PATIENTLEVEL 2 RESPONSE

• Hold the patient

• Use presence as an emotional anchor

• Support the open expression of feelings, doubts and fears

• Explore near-miss events

• Provide information and alternatives for restructuring fearful ideas

• Teach anxiety reduction strategies e.g. focussed breathing, relaxation imagery

• Use contact, therapeutic touch and massage

• Review the day’s events and reduce stressors

• Consult mental health experts

INTERVENTIONS TO ASSIST THE ANXIOUS PATIENT

LEVEL 3 MANAGEMENT• Stay with the patient

• Calm the environment

• Remove any unnecessary auditory, olfactory, visual, tactile and environmental stimulants

• Administer anti anxiety medication

• Use distraction and refocusing techniques

• Repeat realistic reassurances

• Communicate with repetition, clarity and simplicity

• Consult mental health experts

Leavitt 1996

BIPOLAR DISORDER

BIPOLAR DISORDER

• Emotional pendulum• Roller coaster • Manic high

Omnipotent thoughts• Paralysing low

suicidal thoughts• Nurturing calm

SCHIZOPHRENIA

SCHIZOPHRENIASchizophrenia is characterised by ideas of reference, auditory

and/or visual hallucination, thought blocking, delusional association and often the patient believes that they are being persecuted, possessed or accompanied by imaginary figures. There is often mania present with ideas of grandeur and often the individual will feel they possess vital information or talent. There is also often persistent worry, suspicion and anxiety which has no factual basis. In addition there are often severe abnormalities in thought, feeling and behaviour including compulsion.

Schizophrenia is a serious illness which demands our compassion, our patience, our persistence and our utmost respect for the suffering that accompanies this illness.

SCHIZOPHRENIA