Page 1649 - Hematology_ Basic Principles and Practice ( PDFDrive )

1470 Part VIII Comprehensive Care of Patients with Hematologic Malignancies

medications and appear to look better long before their depressive anxiety and depression management. 116,118,119 It is a skill taught to
feelings and suicidal thoughts are relieved. Careful monitoring of patients that takes minimal time. It does, however, require that
suicidal ideation should continue for weeks after the patient appears patients be motivated to learn and practice new techniques as a
improved. way of coping. Cognitive therapy/reappraisal, problem solving, and
A diagnosis of major depression in medically ill patients relies stress management training also have been shown to be helpful in
heavily on the presence of affective symptoms such as hopelessness, the general cancer population. 110,116,120 Fritzsche et al identified that
crying spells, and guilt; preoccupation with death or suicide; feelings a considerable need for psychotherapeutic treatment of inpatient
of diminished self-worth; and loss of pleasure in most activities, such hematology patients is best handled by mental health profession-
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as being with friends and loved ones. The neurovegetative symptoms als. They described a psychosomatic liaison service that provides
that usually characterize depression in physically healthy individuals psychosocial support for patients with hematologic malignancies,
are not good predictors of depression in the medically ill because including patients going through transplant. The service screened
disease and treatment can also produce these symptoms. A combina- patients for anxiety, depression, poor coping, quality of life, and
tion of psychotherapy and antidepressant medication often proves psychosocial openness for support, and provided psychotherapy,
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useful in treating major depression. Patients may need ongoing relaxation training, or group therapy as interventions. Although all
support, reassurance, and monitoring in the period before the anti- transplant patients received support from the team, 23% of the hema-
depressant effects of medication are achieved. Patients must be moni- tology patients on the general ward received additional psychosocial
tored closely by a consistent provider during the initiation and interventions.
modification of psychopharmacologic regimens. In patients with a Other evidence-based interventions that have been found to be
limited prognosis shorter than a few weeks, recent emerging data helpful in the general oncology population include individual and
suggests that ketamine may be useful for the rapid treatment of group counseling, family therapy, and music and art therapy. In
depression. The average time to response is on the order of a few comparison to patients with solid cancers, there should be a low
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hours. It is important to note that although sadness may be present threshold for referral for psychosocial support for patients and families
in the end-of-life period, major depression is not common and should faced with a hematologic malignancy because the primary treatment
be addressed. is intense and long and associated with sensitivity to potential barriers
Psychotropic drugs are highly effective for treatment of anxiety, such as economic constraints, including loss of insurance. It has been
depression, agitation, and confusion in patients with hematologic estimated that one of six cancer survivors with mental health prob-
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malignancies. It is beyond the scope of this chapter to include the lems who need services are unable to access those services due to
96
current medications recommended for common psychiatric disorders. cost. If cost is prohibitive and referral to a psychologist is not fea-
A comprehensive discussion of psychotropic drugs is summarized in sible, both patients and providers must investigate other potential
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the quick pocketbook reference for oncology clinicians. Medica- providers, such as chaplains, art therapists, music therapists, social
tions specific for the management of anxiety, depression, and delirium workers, and psychiatric advanced practice nurses who might be able
also are presented. to see patients as part of their work responsibilities. Other possibilities
include online support groups and advocacy organizations, including
local wellness communities.
Psychotherapeutic Modalities Depending on the nature of the problem, the treatment modality
may take the form of individual psychotherapy, group therapy,
“Returning to normal” is a prominent theme and desired goal in the family therapy, marital therapy, cognitive or behaviorally oriented
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clinical management of patients but is not always possible for patients therapy, or some combination. Increasing evidence supports use of
with hematologic malignancies. 92,116 Survivors of cancer continue to an aerobic exercise program for patients with hematologic
face challenges with long-term physical and psychologic symptoms malignancies. 121–123 Researchers have concluded that fatigue and loss
long after treatment has ended, and data indicate that they report of physical performance in patients undergoing HSCT may improve
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more contact with mental health providers than do people without with exercise. Others have found increased muscle strength with
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cancer. The ASBMT released a joint statement recommending supervised weight bearing and lifting after allogeneic HSCT. Table
screening and preventive practices for long-term survivors of hema- 90.3 outlines the major psychotherapeutic modalities and their
topoietic cell transplantation. The recommendation states that “a advantages, goals, and indications.
high level of vigilance for psychologic symptoms should be main-
tained. Clinical assessment is recommended throughout the recovery
period, at six months, one year, and annually thereafter, with mental FUTURE DIRECTIONS
health professional counseling recommended for those with recog-
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nized deficits.” The number of intervention studies designed with The psychosocial issues faced by people diagnosed with and treated
the hematologic population is limited; however, growing interest in for hematologic malignancies are influenced by individual, environ-
survivorship is changing the research climate in this area. mental, and disease-related factors. Because involvement in decision
Support groups can provide a therapeutic experience for patients making clearly is a positive aspect of current cancer therapies, great
and family members. Initial evidence suggests that support groups care should be taken to ensure that communication is timely, repeated,
may help reduce health care costs along with depression, mood dis- relevant, and consistent with the patient’s needs, tolerance for infor-
117
turbance, and psychiatric symptoms in patients. Patients often feel mation, and comprehension. A multidisciplinary approach is neces-
alone in their distress and report that sharing a common experience sary to guarantee the communication of timely and essential
normalizes their feelings, provides an avenue for emotional support, information to patients and family members. Patients should be given
facilitates dialogue to problem solve, and offers opportunities to learn the opportunity to speak with multiple members of the multidisci-
from other patients. Support groups facilitated by professionals such plinary treatment team and other patients who have experienced
as social workers, nurses, or psychologists can provide a forum for similar management and treatment protocols. Care should be taken
health and psychologic education and provide patients with printed to provide needed information from a variety of expert perspectives
literature and online community-based resources. Sherman et al while respecting the unique characteristics, psychosocial profiles,
found that psychoeducational support groups facilitated by profes- needs, and desires of each individual. In treatment settings with
sionals were a helpful strategy for psychologic recovery in patients’ limited resources, every effort should be made to enlist the help and
post-HSCT. 26 support of providers and services that can assist patients with treat-
Other modalities have been shown to be effective with ment decisions and their complex management. Referral to com-
patients. 82,92 Studies have consistently shown that relaxation train- munity resources and support services after discharge from the
ing with or without guided imagery or hypnosis may have some hospital often is helpful, even for patients who cope well with initial
benefit with improving quality of life, symptom management, and treatment. 124