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Psychological Interventions in Palliative Care PDF
Psychological Interventions in Palliative Care PDF
Psychological Interventions in Palliative Care PDF
CURRENT
OPINION Psychological interventions in palliative care
Pia von Blanckenburg and Nico Leppin
Purpose of review
To provide an update on recent studies about psychological interventions in palliative (mainly cancer) care
with a focus on physical, psychological, spiritual, and social aspects.
Recent findings
Some promising psychological interventions for physical challenges, such as fatigue, pain, dyspnea, and
insomnia do exist, but further research is needed. Regarding psychological aspects, current reviews
showed small to large effects in the reduction of depression and anxiety symptoms through cognitive
behavioral-based interventions, mindfulness-based interventions, and meaning-based interventions.
Meaning-based or dignity-based approaches were also used for targeting spiritual aspects or existential
distress. Social aspects that play a crucial role in palliative care are addressed by social support
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interventions, end-of-life discussions, and advanced careplanning. All of these psychological interventions
must meet the specific requirements of palliative care, namely abbreviated session time and flexibility
concerning locality of interventions, a minimized questionnaire burden and a high attrition rate caused by
patients’ poor physical conditions or deaths.
Summary
There is substantial research on psychological interventions in palliative care that shows promising results,
but sample sizes were often small. Due to its high relevance for this growing patient group, there is a
strong need for ongoing/further research.
Keywords
end of life, meaning-based therapy, palliative cancer care, psychological interventions
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meaning-based
intervenons, dignity-
based and life review
intervenons
Spiritual
CBT, facilitate social
mindfulness- anxiety, loss sense of support,
of control, isolaon,
based Psycho- advanced care
depression, communicaon
intervenons
change in life Social about disease
planning, end-
and meaning- logical of-life
goals and self topics, changes
based image in interacons communicaon
intervenons and discussion
Physical
fague, lack of
energy, weakness,
dyspnea, insomia,
pain, immobility.
appete loss
challenges in the
palliave seng
recent psychological
intervenons in the field
overview of typical challenges emerging in the pal- the past 10 years, one RCT and two feasibility studies
&&
liative phase. All aspects interact with each other showed an effect on dyspnea [18 ]. The RCT
and affect patients just as their loved ones. The listed focused on psychoeducation and progressive muscle
psychological interventions were investigated in the relaxation and revealed small effects on breathless-
past year and seldom focus on a single aspect but are ness and fatigue. The feasibility studies made use of
listed where they are most effective. group exercise, relaxation, and breathing techni-
ques. The data from the pilot patients pointed in
a positive direction. Insomnia or sleep impairments
PSYCHOLOGICAL APPROACHES are also common in advanced cancer patients.
Savard and Savard announced that they would soon
Physical aspects publish results of their pilot study, which uses cog-
Occurring in more than 50% of the patients, the five nitive behavioral and environmental therapy target-
most prevalent physical symptoms in advanced ing insomnia [19]. CBT has proved to be effective for
cancer are fatigue, pain, weakness, lack of energy, physical symptom management in earlier stages of
and appetite loss [11]. Even with an optimal dosing cancer, but there is an urgent need for further
of medication relief from these symptoms is not research in a palliative setting.
guaranteed for every palliative patient [12]. Still,
looking at the example of cancer pain management,
recommendations focus on pharmacological solu- Psychological aspects
tions. Psychological approaches are rather viewed as Occurring in approximately one third of palliative
last or ultimate step, although biopsychosocial cancer patients, the most frequent psychiatric dis-
models of cancer pain are widely accepted. In the orders are depression, adjustment disorder, and anx-
past year, no RCT was published on psychological iety disorders [20]. Two current meta-analyses
interventions for pain reduction in palliative care showed that psychological interventions are effec-
settings. Though, Brugnoli et al. conducted a non- tive in reducing depressive symptoms in palliative
randomized clinical trial on a long-term interven- && &&
samples [21 ,22 ]. Okuyama et al. reported moder-
&
tion using clinical hypnosis and self-hypnosis [13 ]. ate effect sizes of depression reduction over 12 RCTs
In weekly meetings, a group of 25 patients learned among incurable cancer patients, but the studies
hypnosis techniques like self-suggestion, reinterpre- &&
included were of low quality [22 ]. Although the
tation, and positive visualization. The resulting pain European guidelines on the management of depres-
and anxiety reduction in the treatment groups are sion in palliative cancer care recommend that ‘clini-
very promising. Additionally, a study protocol from cians should consider psychological therapy for
Carson et al. describes a mindful yoga intervention treatment of depression in palliative care’ [23],
that will be tested in a RCT [14]. The use of breathing high-quality studies on this subject are lacking. A
techniques, meditation, yogic principles to optimal minimized questionnaire burden and high attrition
coping and group discussions shall lead to reduced rates due to patients’ poor physical conditions and/
pain and fatigue. or deaths lead to difficulties producing high-quality
Persistent tiredness (fatigue) is perceived as one studies in this field. Fulton and colleagues analyzed
of the most distressing symptoms among advanced 32 RCTs, including 1536 patients with various con-
cancer patients and is strongly associated with ditions relevant to palliative care, in which half of
reduced activity levels and a decrease in quality of the studies focused on cancer patients [21 ]. They
&&
life [15]. Poort et al. reviewed 14 studies on psycho- found large effect sizes of reduced depression symp-
social interventions for fatigue, concluding that toms and small effects of reduced anxiety symp-
evidence quality was very low and effect estimates toms. By comparison, CBT and mindfulness-based
&&
could therefore not be trusted [16 ]. The question- interventions had greater effects on symptom reduc-
able effect estimates convey benefits of psychologi- tion than dignity-based interventions [21 ].
&&
cal interventions, as compared with controls at the The core of mindfulness-based interventions
first follow-up (but not at postintervention or the focuses on the ‘here-and-now’, which may help
second follow-up). The same research group also patients in palliative settings to live 1 day at a time
designed a study protocol that expressed intent to and to better cope with their situations. A recent
examine the effects of cognitive-behavioral therapy systematic review of mindfulness-based interven-
(CBT) on fatigue, as compared with usual care and tions showed medium effect sizes in depression,
&
graded exercise therapy in a RCT [17 ]. anxiety, self-compassion, cancer-specific quality of
Another physical problem, especially for ad- life, and mindfulness [24]. Nevertheless, based on
vanced lung cancer patients, is shortness of breath their RCT on a mindfulness-based cognitive group
or dyspnea. In Lehto’s recent review of research from therapy conducted by telephone, Chambers et al.
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argue that certain patient groups might not profit preliminary efficacy outcomes [31]. Thus, it is pos-
from this approach. They did not find any effects sible that the psychological care for palliative
on psychological distress, cancer-specific distress, or patients could be augmented using online services
prostate-specific antigen anxiety in men with or interdisciplinary approaches. However, the inte-
&
advanced prostate cancer [25 ]. The authors argued gration of clinical psychologists and psychiatrists
that other interventions that consider male-specific in palliative care within a stepped care approach
support needs and coping styles could be more is essential, because interventions delivered by men-
favorable for these patients. Including spouses/ tal health providers seem to be more effective
partners could be another possible topic for future than interventions administered by other health-
&&
research, as an interesting pilot study of a couple- care staff [21 ].
based mind–body intervention for metastatic
&
lung-cancer patients recently has shown [26 ]. The
intervention focused within four sessions on mind- Spiritual aspects
fulness, connection, gratitude, and purpose. It Existential and spiritual distress can be seen as a
included techniques as meditation and education distinct dimension of distress and can occur inde-
about mindfulness, a guided visualization exercise, pendently from, or together with, psychological
lessons of compassionate listening, reflection on distress [32]. Existential distress may include death
core values/ things to be grateful for. First results anxiety, loss of important roles, sense of isolation,
showed promising effects on patients’ sleep-distur- and regrets about the past. The desire for hastened
bances, cancer-related distress, as well as their part- death, a loss of dignity, and demoralization are
ners’ depression scores. clinically relevant syndromes that occur among
Interestingly, although interventions with a approximately 10–25% of advanced cancer patients
greater number of treatment sessions resulted in a [33–35]. Vehling et al. argued that the most impor-
greater reduction of symptoms, longer treatment tant intervention principle for dealing with existen-
&&
sessions resulted in fewer effects [21 ]. This finding tial fears is the counterbalancing of confrontation
may reflect the inability of palliative patients to (e.g., planning and preparing) and deflection (e.g.,
endure long treatments. Hence, more frequent by use of meaningful daily life activities) [36]. A
and shorter sessions could be more beneficial com- current review that examined death anxiety inter-
pared with fewer and longer sessions. These results ventions in 1178 advanced cancer patients distin-
were confirmed by a study in the United Kingdom guished between two types of interventions:
asking psychotherapists for their experiences with Meaning-based interventions and dignity-based
& &
advanced cancer patients [27 ]. Due to poor physical interventions [37 ].
conditions, medication, and cognitive difficulties, Meaning-based interventions discuss existential
more flexibility regarding the length and scheduling themes such as death openly and help patients to
of appointments is required. cope with loss and grief, renegotiate life goals, make
Although mental disorders are quite common in peace with missed opportunities, and live with
palliative cancer samples [20], the majority of palli- uncertainty [38]. One important approach is Rose-
ative physicians reported difficulties accessing psy- nfeld et al.’s meaning-centered psychotherapy
chological and psychiatric services [28]. Difficulties (MCP) that has recently been adapted to patients
&
often arise due to a lack of local service provisions, in their last weeks of life [39 ]. The individual ver-
staff shortages, or waiting times that are inappropri- sion of MCP was currently evaluated in a large RCT
&&
ately long for patients with such prognoses. To take [40 ]. A total of 321 patients were allocated to either
a step toward overcoming these problems, a small individualised meaning-centered psychotherapy
pilot trial in the United Kingdom evaluated the (IMCP), supportive therapy, or enhanced usual care.
effectiveness of a short and focused narrative inter- IMCP showed the strongest effects on overall quality
&
vention among palliative cancer patients [29 ]. The of life, sense of meaning, and spiritual well being.
intervention contained the reflection about contrib- Effect sizes were small to moderate compared with
uting factors of depression and about own inner usual care, and small compared with supportive
resources and coping methods. The authors empha- therapy. The authors therefore highlight the im-
size that this intervention could be conducted by portance of addressing existential issues with
any member of a palliative care team according to patients approaching the end of life. Rosenfeld
&
clinical practice [30 ]. Another recent pilot trial et al. analyzed the mechanisms of change in MCP
comparing a CBT intervention (targeting mindful- and found an enhanced sense of meaning as
ness, gratitude, and positive reappraisal) conducted a particularly powerful mediator of increased
&
meetings online and in person and did not quality of life and decreased depression [41 ].
find any differences in feasibility, acceptability, or Another important meaning-based approach is the
0951-7367 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 393
therapy for severe fatigue or cognitive behaviour therapy with usual care in
They are currently receiving grants from the German patients with incurable cancer. BMC Cancer 2017; 17:1–12.
This is a study protocol of a three-armed multicenter RCT, involving CBT that
Ministry of Education and Research for a large palliative focuses on individual fatigue-perpetuating factors. Target sample size is an-
care intervention trial. nounced with 219 participants at T0.
18. Lehto RH. Psychosocial challenges for patients with advanced lung cancer:
&& interventions to improve well being. Lung Cancer 2017; 8:79–90.
Financial support and sponsorship A systematic review summarizing the major types of psychosocial interventions
addressing challenges for patients with advanced lung cancer. Despite patients’
None. very poor physical functioning, lung cancer remains understudied in the area of
psychosocial care as compared with other cancers.
19. Savard M-H, Savard J. Cognitive-behavioral therapy for insomnia in cancer
Conflicts of interest patients: an update of efficacy evidence and areas for future research. Curr
There are no conflicts of interest. Sleep Medicine Rep 2017; 3:66–75.
20. Mitchell AJ, Chan M, Bhatti H, et al. Prevalence of depression, anxiety, and
adjustment disorder in oncological, haematological, and palliative-care set-
tings: a meta-analysis of 94 interview-based studies. Lancet Oncol 2011;
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&& of outstanding interest
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This study confirms the effects of individual meaning-centered psychotherapy on of ACP and recommendations for its application were provided. Also, a brief
both psychological and existential distress. overview on the effects of ACP is given.
0951-7367 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 395