APOS Clinical E-Mail Update #18
8 July 2005

In this Update:

What happens if the Oregon patient requesting physician-assisted suicide has a mental disorder?

Hamilton NG, Hamilton CA.  Competing paradigms of response to assisted suicide requests in Oregon.  Am J Psychiatry 2005; 162:1060-1065.

This case understates how a patient with grave illness may or may not get care for serious and treatable psychiatric syndromes because one group is intimidated by the nature of cancer and cancer treatment, and the other is intimidated by psychiatric treatment.  Only 5% of patients who consider assisted suicide in Oregon are sent for mental health consultation.1

This case conference highlights the conflict between two competing models of response to assisted suicide requests in Oregon.  The authors describe in detail the story of a man diagnosed with lung cancer who begins to request assisted suicide at the time of cancer diagnosis.  The patient has a history of suicide attempts, a family history of suicide, substance abuse, and depression.  The case calls attention to the tension between the traditional clinical psychiatric model and the assisted suicide competency model.  The clinical model allows that patients who are suicidal may suffer from treatable depression and are ambivalent about the desire for death.  If not clinically depressed, they also may be demoralized with depressive symptoms and irrational hopelessness.  The traditional professional response is to assess the patient carefully, beginning with an interview aimed at empathic understanding.  The psychiatrist takes a history that allows consideration of recent stresses, past medical and psychiatric history, and organic factors that may contribute to the present mental status.  Sources of hope, self-esteem, and strength are explored.

The second model is the competency evaluation, specifically focused on capacity of the individual to make a decision for physician assisted suicide.  Factors that limit competency like mental disorder, knowledge deficits, and coercion are considered.  The presence of depression does not itself mean that the patient is incompetent.

The described patient with lung cancer has a variety of psychiatric presentations during the course of his illness.  Psychiatric assessment includes an understanding of the relapsing course of depressive illness, the differential diagnosis of paranoia, the high rate of delirium and cognitive impairment from medications, and common scenarios in patients with this personal history and character structure.  Psychiatrists and other mental health providers have expert knowledge in recognition and treatment of these syndromes.  They are practiced at talking with patients about questions of suicide.  If the patient here were presenting with various degrees of congestive heart failure or myocardial infarction, we might think that we could agree on a standard of knowledge and care.  The same should apply to the standard for treatment of psychiatric ailments.  However, the knowledge base of psychiatrists and other mental health professionals is not well understood.  This case serves as a good platform for beginning the discussion.

1.  Oregon Department of Human Services: Sixth Annual Report on Oregonís Death With Dignity Act, March 10, 2004 http://www.ohd.hr.state.o9r.us/chs/pas/ar-index.cfm

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Is it useful to screen for depression in cancer inpatients?

Shimizu K, Akechi T, Okamura M, Oba A, Fujimori M, Akizuki N, Uchitomi Y.  Usefulness of the nurse-assisted screening and psychiatric referral program.  Cancer 2004;103:1949-56.

This study adds to our understanding of models of care to facilitate diagnosis of depressive disorder in cancer patients.  In the setting of a Japanese oncology practice, nurses screened patients for depressive disorder.  After an initial interview for patients admitted to the 42-bed Oncology/Hematology Unit, nurses asked patients if they would fill out the screening instrument for psychological distress If the patient scores positive, then a psychiatric referral was offered.  Most of the patients who were offered a psychiatric referral declined, but compared to the state of care before the study, the recognition of clinical depression was still better in patients positive on screening who allowed psychiatric evaluation.

The nurses used a 2-item Impact Thermometer self-report scale with the Distress Thermometer, a 0-10 measure of distress.  The Impact Thermometer adds an 11-point Likert scale from 0-10 to the measure of distress on the Distress thermometer.  Cut-off points were 4 for distress and 3 for impact for both major depressive disorder and adjustment disorder.  For major depressive disorder only, the cut off was 5 for distress and 4 for impact.

If the screen was positive, two trained psychiatrists could evaluate the patient with an interview and the criteria of the Diagnostic Statistical Manual; however, the patients had to accept psychiatric referral.  All the cases were discussed at weekly meetings, and nurses had training from psychiatrists before the study.

Without this screening and programmatic enhancement, 5 patients (2.5% of 163 patients) had been referred to psychiatry: one with depression, one with delirium, and 3 with adjustment disorders.  After the enhanced program, 19 patients were referred: 6 with major depression, 9 with adjustment disorder, one with bipolar disorder II in remission, and 3 with no psychiatric diagnosis.  The proportion referred with major depressive disorder was significantly greater with the enhanced program (11.5%) than with historical usual care (2.5%).  The ad hoc clinical monitoring of moderate or severe distress by physician and nurse was the historical pattern for referral.

With this screening tool, the Distress and Impact Thermometer, 50% of patients screened positive, but 71% of the 67 patients refused psychiatric consultation.  The screening results about psychological distress were fed back to the nurses, so that they could be alert to opportunities to help the distressed patients.

It is noteworthy that the proportion of distressed cancer patients who accepted psychiatric referral, around 28%, was similar in Japan and Australia.  Across cultures, patients may be fearful of a psychiatric evaluation or concerned about losing face as a psychiatrist approaches.  However, the medical differential diagnosis improved by specialty providers is a matter of quality medical care.  The patientís willingness to have a psychiatric consultation should be evaluated against the physicianís willingness to do without a consultation.  The psychiatric referral should be weighed against the value of an appropriate cardiological or renal evaluation requested by the attending oncologist. 

Other recent articles on psychological consultation in a cancer center include:

1. Sharpe M, Strong V, Allen K, et al.  Management of major depression in outpatients attending a cancer center: a preliminary evaluation of a multi-component cancer nurse-delivered intervention.  Br J Cancer.  2004; 90:310-313.

2. Curry C, Cossich T, Matthews JP, et al.  Uptake of psychosocial referrals in an outpatient cancer setting: improving service accessibility via the referral process.  Support Care Cancer.  2002;10:549-555.

3. Passik SD, Kirsh KL, Theobald D et al.  Use of a depression screening tool and a fluoxetine-based algorithm to improve the recognition and treatment of depression in cancer patients.  A demonstration project.  J Pain Symptom Manage.  2002;24:318-327.

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Breast cancer patients who walk seem to live longer; how do you get them to walk?

Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz G.  Physical activity and survival after breast cancer diagnosis.  J Amer Medical Assoc 2005;293:2479-2486.

Walking 3 to 5 hours per week at an average pace after the diagnosis of breast cancer correlated with longer survival.  Physical exercise, mostly walking, reduced the risk of death from breast cancer in a prospective observational study based on responses from about 3000 registered nurses in the Nursesí Health study who were diagnosed with breast cancer stages I, II, or III, between 1984 and 1998.  The benefit of physical activity was more apparent in women with hormone-responsive tumors.  The benefit did not relate to amount of energy expended.  The study subjects were professional and 98% white.

Pinto BM, Frierson GM, Rabin C, Trunzo JJ, Marcus BH.  Home-based physical activity intervention for breast cancer patients.  J Clin Oncol 2005; 3577-3587.

In order to get women with Stages 0-II breast cancer to be more physically active at home, these researchers developed a program for sedentary women, average age 53.  The women were randomized to the intervention or to a contact control group.

Subjects in the intervention group (n= 43) were instructed in-person how to exercise at a moderate-intensity level, how to monitor pulse, how to warm up and cool down.  They had home logs to monitor participation and a pedometer to wear during walks.  Recommended exercise began at the quantity of 10 minutes for 2 days each week, with a gradual increase to 30 minutes per day on at least 5 days per week.  Brisk walking, biking, swimming, and use of home exercise equipment at 55-65 percent of maximum heart rate, were suggested.  In the weekly phone call, patients were guided to set small, achievable goals, identify potential barriers, and problem solve to achieve goals.  The counseling was tailored to the phase of motivatonópre-contemplation or preparation.  Women were advised how specifically to reduce the risk of lymphedema when they exercised.  On the weekly calls, the patients reported the data in their home logs and received feedback.  At the end of the intervention, they received weekly mailed tips for survivorship and a feedback letter summarizing their progress.

The control group (n=43) was asked to keep their activity the same over 12 weeks.  They received weekly phone calls, tip sheets, and the Symptom Questionnaire over the phone

The intervention group was more active and more fit in a field test.  However, these changes were not reflected by differences in pedometer data.  The intervention group was more likely to be motivated to be active and to meet exercise guidelines after treatment.  After treatment the group who had the activity intervention had less fatigue, more vigor, and a tendency to better overall mood and body image.

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Are hot flashes of breast cancer survivors different?

Carpenter JS, Gilchrist JM, Chen K, Gautam S, Freedman RR.  Hot flashes, core body temperature, and metabolic parameters in breast cancer survivors.  Menopause.  2004; 11:375-581.

Hot flashes are usually most frequent at 6:30 pm when core temperature peaks each day.  Women with hot flashes have a narrower temperature null zone, the range of temperature that is too warm to shiver and too cold to sweat.  To see if the hot flashes of breast cancer survivors also had these characteristics, these researchers took nine post-menopausal breast cancer survivors with daily hot flashes into a metabolic room where they could control temperature and humidity and could measure energy output.  Four of these patients were taking tamoxifen.  None had active cancer.  These patients had hot flashes spread throughout the day and night.  The study showed that these cancer survivors who were estrogen deficient were like their menopausal counterparts suffering hot flashes mediated by a central nervous system abnormality.  A hot flash was defined as an increase of two mmho skin conductance within a 30-second period.

For all the women who were breast cancer survivors, circadian rhythm of core temperature was disrupted.  The core temperature began to rise about 20 minutes to 7 minutes before the woman had a hot flash; this finding is similar in healthy women.  Each documented hot flash was associated with an increase in energy expenditure and respiratory quotient.  This is a small sample of breast cancer survivors that gives a clue to hot flash patterns seen in breast cancer patients.

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What is a useful treatment targeted for complicated grief?

Shear K, Frank E, Houck PR, Reynolds CF.  Treatment of complicated grief: a randomized controlled trial.  J Amer Medical Assoc 2005;293:2601-2608. 

Complicated grief, distinct from major depressive disorder, describes a syndrome present more than six months after a major loss.  It includes a sense of disbelief regarding the death, anger and bitterness over the death, recurrent pangs of painful emotions with intense yearning and longing for the deceased; and preoccupation with thoughts of the loved one, often including distressing intrusive thoughts related to the death.  This is a syndrome measured by the Inventory of Complicated Grief,1 an instrument developed by Prigerson et al to measure maladaptive symptoms to loss.  A portion of those with complicated grief may also have major depressive disorder or post-traumatic stress disorder, but the majority do not.  Among bereaved persons the prevalence of complicated grief is 10-20 percent.

In this study of 83 women and 12 men, 49 were randomized to receive interpersonal psychotherapy (IPT) or complicated grief treatment (CGT).  Both treatments were given in 16 sessions over 19 weeks.  Both treatments were helpful, but Complicated Grief Treatment led to improvement in 51% compared to 28% in those who took Interpersonal Therapy.  The treatment response was measured by an evaluator-rated Clinical Global Improvement score or a change in the score on the Inventory of Complicated Grief.  All therapists were masterís or doctoral-level clinicians with two or more years psychotherapy experience.  They were certified in either therapy type and supervised with the availability of videotape examples during supervision sessions.

Complicated Grief Treatment, delivered according to a manual protocol, also included an introductory, middle and termination phase.  The initial treatment included education about normal and complicated grief.  The therapists used a dual-process model of adaptive coping, which entailed both restoration of a satisfying life and adjustment to loss.  In the middle phase, attention to loss and personal life goals become the focus in tandem.  The termination phase focused on review of progress, plans for the future, and feelings about ending treatment.

This treatment differs from IPT because it includes procedures modified from treatments for post-traumatic stress disorder like in vivo exposure or imaginal exposure to traumatic grief-laden situations.  Complicated Grief Treatment included a procedure for retelling the story of the death and exercises that entail confrontation with avoided situations.  In the revisiting experience, the patient closes his eyes and tells the story of the death.  The therapist tape-records the story and periodically asks the patient to report distress levels.  The patient could listen to the tape at home during the week.  To influence yearning and fear of losing the deceased forever, techniques to promote connection were brought in.  Patients had imaginary conversations with the deceased.  These conversations were done with patientís eyes closed for 10-20 minutes.  Questionnaires asked about mostly positive and some negative memories.  Therapists discussed concrete plans with patients in order to help patients get to life goals as they would have done if the grief were not so intense.

In this study, about half the patients responded to this treatment.  Patients taking antidepressant medication prior to starting this study did have a slightly better outcome than those without medications.  One third of patients were grieving for dear ones who died violently.  African American patients comprised 22 percent of the sample.

1. Prigerson HG, Maciejewski PK, Reynolds CF, et al.  Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss.  Psychiatry Res.  1995;59:65-79.

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Do 5-HT3 antagonist antiemetics cause nervous system problems in the elderly?

Tralongo P, Dimari A, Conti G, Aiello R, Mauceri G.  Central nervous system side-effects of 5-HT3-receptor antagonists in elderly cancer patients treated with chemotherapy.  Ann Oncology 2004;987-988.

Central nervous system side effects are more important to sort out in elderly patients.  From ondansetron or granisetron, headaches were reported in about one quarter of older patients, abnormal vision in about 5%, and dizziness in about 10%.  These agents prevent vomiting and nausea with chemotherapy and radiation.  Ondansetron and granisetron have equivalent efficacy in moderate to severe emetogenic chemotherapy in 14 trials.  Dizziness and lightheadedness occurred in 11% and 21% of patients treated with ondansetron.  Difficulty with vision was reported more commonly for ondansetron than granisetron.  In 58 patients older than 70 years, given either 3 mg IV granisetron or 16 mg ondansetron 30 min before chemotherapy, the treatment continued until 2 days after chemotherapy (with granisetron as 2 mg orally or 8 mg sublingual ondansetron).  For the 22 patients with CNS side effects evaluated at the next outpatient visit, neither drug was significantly more or less responsible.

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Donna B. Greenberg, MD, Associate Professor of Psychiatry at Harvard Medical School and Psychiatric Consultant in the Massachusetts General Hospital Cancer Center, Dana Farber Partners Cancer Care