Overview of anxiety in palliative care
- Scott A Irwin, MD, PhD
Scott A Irwin, MD, PhD
- Associate Professor of Psychiatry
- Director, Supportive Care Services
- Samuel Oschin Comprehensive Cancer Institute
- Cedars-Sinai Medical Center
- Jeremy M Hirst, MD
Jeremy M Hirst, MD
- Professor of Psychiatry and Behavioral Neurosciences
- Associate Director, Palliative Care Psychiatry
- University of UC San Diego Health
- Director of Psychiatry & Psychosocial Services; Patient & Family Support Services
- University of California San Diego, Moores Cancer Center
- Section Editor
- Susan D Block, MD
Susan D Block, MD
- Editor-in-Chief — Palliative Care
- Section Editor — Psychosocial Issues
- Professor of Psychiatry
- Harvard Medical School
- Deputy Editors
- Diane MF Savarese, MD
Diane MF Savarese, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Oncology and Palliative Care
- Clinical Instructor of Medicine
- Harvard Medical School
- Richard Hermann, MD
Richard Hermann, MD
- Deputy Editor — Psychiatry
- Associate Professor
- Tufts University School of Medicine
For most patients in palliative care, symptoms of anxiety are normal and are expected consequences given the uncertainties of living with serious illness and the possibility of approaching death. Anxiety is generally described as a feeling of helplessness or fear, often related to a sense of losing control that frequently accompanies life with illness, as well as being generated by death-related factors. A patient’s distress may also be related to physical, psychological, social, spiritual, practical, end of life, and loss issues [1,2]. They express fears about what their death will look and feel like and what events will lead up to it. They frequently voice concerns about religious beliefs, spiritual issues, existential matters, or how to achieve a good death. Some people with anxiety may require intervention and some may not. Often reassurance, presence, addressing their concerns directly, and controlling symptoms is all that is needed.
While many patients with serious illness have worries, fears, and apprehensions, they do not usually rise to the level of an anxiety disorder. That is, anxiety disorders should not be assumed to be an inevitable part of serious illness . However, for other patients symptoms of anxiety can be severely debilitating and require intensive treatment. At the most extreme, out of control anxiety can sometimes lead to a heightened interest in a hastened death .
The detrimental impact of untreated, persistent anxiety was demonstrated in one multicenter study of over 600 patients with advanced cancer that evaluated associations between anxiety disorders and multiple endpoints, including physician-patient relationships . Patients with anxiety disorders had less trust in their clinicians compared to those without anxiety. In addition, patients with anxiety reported being:
●Less comfortable asking questions about their health
●Less likely to understand the clinical informationTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Payne DK, Massie MJ. Anxiety in palliative care. In: Handbook of Psychiatry in Palliative Medicine, Chochinov HM, Breitbart W (Eds), Oxford University Press, New York 2000. p.435.
- Atkinson JH Jr, Grant I, Kennedy CJ, et al. Prevalence of psychiatric disorders among men infected with human immunodeficiency virus. A controlled study. Arch Gen Psychiatry 1988; 45:859.
- Breitbart W, Chochinov HM, Passik S. Psychiatric symptoms in palliative medicine. In: Oxford Textbook of Palliative Medicine, 3rd ed, Doyle D, Hanks GWC, Cherny NI, Calman K (Eds), Oxford University Press, New York 2005. p.747.
- Alici Y, Levin TT. Anxiety disorders. In: Psycho-oncology, 2nd ed, Oxford University Press, New York 2010. p.324.
- Zuckoff A, Shear K, Frank E, et al. Treating complicated grief and substance use disorders: a pilot study. J Subst Abuse Treat 2006; 30:205.
- Massie MJ, Shakin E. Management of depression and anxiety in cancer patients. In: Psychiatric Aspects of Symptom Management in Cancer Patients, Breitbart W, Holland JC (Eds), American Psychiatric Pub, Washington, DC 1993. p.1.
- Spencer R, Nilsson M, Wright A, et al. Anxiety disorders in advanced cancer patients: correlates and predictors of end-of-life outcomes. Cancer 2010; 116:1810.
- Shalev AY, Schreiber S, Galai T, Melmed RN. Post-traumatic stress disorder following medical events. Br J Clin Psychol 1993; 32 ( Pt 2):247.
- Smith MY, Redd W, DuHamel K, et al. Validation of the PTSD Checklist-Civilian Version in survivors of bone marrow transplantation. J Trauma Stress 1999; 12:485.
- Kangas M, Henry JL, Bryant RA. Posttraumatic stress disorder following cancer. A conceptual and empirical review. Clin Psychol Rev 2002; 22:499.
- Andrykowski MA, Kangas M. Posttraumatic stress disorder associated with cancer diagnosis and treatment. In: Psycho-Oncology, 2nd ed, Holland JC, Breitbart WS, Jacobsen PB, et al (Eds), Oxford University Press, New York 2010. p.348.
- Irwin SA, Fairman N, Montross LP. UNIPAC 2: Alleviating Psychological and Spiritual Pain. In: UNIPAC: Hospice and Palliative Care Training for Physicians Self-Study Program, 4th ed, Storey Jr CP (Ed), 2012.
- Irwin SA, Montross LP, Chochinov HM. What treatments are effective for anxiety in patients with serious illness. In: Evidence-Based Practice of Palliative Medicine, Morrison RS, Goldstein N (Eds), Elsevier Saunders, 2012. p.191.
- Block SD. Psychological issues in end-of-life care. J Palliat Med 2006; 9:751.
- Wilson KG, Chochinov HM, Skirko MG, et al. Depression and anxiety disorders in palliative cancer care. J Pain Symptom Manage 2007; 33:118.
- Fava GA, Porcelli P, Rafanelli C, et al. The spectrum of anxiety disorders in the medically ill. J Clin Psychiatry 2010; 71:910.
- Anderson WG, Alexander SC, Rodriguez KL, et al. "What concerns me is..." Expression of emotion by advanced cancer patients during outpatient visits. Support Care Cancer 2008; 16:803.
- Andersen BL, DeRubeis RJ, Berman BS, et al. Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation. J Clin Oncol 2014; 32:1605.
- Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics 2009; 50:613.
- Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166:1092.
- Löwe B, Decker O, Müller S, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care 2008; 46:266.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed: DSM-5, American Psychiatric Press, Washington, DC 2013.
- Rosenbaum JF. The drug treatment of anxiety. N Engl J Med 1982; 306:401.
- Austin P, Wiley S, McEvoy PM, Archer L. Depression and anxiety in palliative care inpatients compared with those receiving palliative care at home. Palliat Support Care 2011; 9:393.
- Bruera E, MacEachern T, Ripamonti C, Hanson J. Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med 1993; 119:906.
- Irwin SA, Pirrello RD, Hirst JM, et al. Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. J Palliat Med 2013; 16:423.
- Roth A, Nelson CJ, Rosenfeld B, et al. Assessing anxiety in men with prostate cancer: further data on the reliability and validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Psychosomatics 2006; 47:340.
- Lo C, Hales S, Jung J, et al. Managing Cancer And Living Meaningfully (CALM): phase 2 trial of a brief individual psychotherapy for patients with advanced cancer. Palliat Med 2014; 28:234.
- Nissim R, Freeman E, Lo C, et al. Managing Cancer and Living Meaningfully (CALM): a qualitative study of a brief individual psychotherapy for individuals with advanced cancer. Palliat Med 2012; 26:713.
- Akechi T, Okuyama T, Onishi J, et al. Psychotherapy for depression among incurable cancer patients. Cochrane Database Syst Rev 2008; :CD005537.
- Greer JA, Traeger L, Bemis H, et al. A pilot randomized controlled trial of brief cognitive-behavioral therapy for anxiety in patients with terminal cancer. Oncologist 2012; 17:1337.
- Kissane DW, Grabsch B, Clarke DM, et al. Supportive-expressive group therapy for women with metastatic breast cancer: survival and psychosocial outcome from a randomized controlled trial. Psychooncology 2007; 16:277.
- Chochinov HM, Kristjanson LJ, Breitbart W, et al. Effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial. Lancet Oncol 2011; 12:753.
- Martínez M, Arantzamendi M, Belar A, et al. 'Dignity therapy', a promising intervention in palliative care: A comprehensive systematic literature review. Palliat Med 2017; 31:492.
- Breitbart W, Poppito S, Rosenfeld B, et al. Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. J Clin Oncol 2012; 30:1304.
- Kissane DW, Grabsch B, Love A, et al. Psychiatric disorder in women with early stage and advanced breast cancer: a comparative analysis. Aust N Z J Psychiatry 2004; 38:320.
- Goy ER, Ganzini L. Prevalence and natural history of neuropsychiatric syndromes in veteran hospice patients. J Pain Symptom Manage 2011; 41:394.
- Ayers CR, Sorrell JT, Thorp SR, Wetherell JL. Evidence-based psychological treatments for late-life anxiety. Psychol Aging 2007; 22:8.
- Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry 1999; 156:1.
- Cook IA. Guideline watch: Practice guideline for the treatment of patients with delirium. 2004. www.psychorg/psych_pract/treatg/pg/prac_guidecfm (Accessed on December 01, 2012).
- Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996; 153:231.
- Rundell JR, Wise MG, Press AP. Essentials of consultation liaisonpsychiatry: Based on the American Psychiatric Press textbook of consultation-liaison psychiatry, American Psychiatric Press, Washington, DC 1999.
- Marcantonio ER. In the clinic. Delirium. Ann Intern Med 2011; 154:ITC6.
- Trivedi MH, Rush AJ, Carmody TJ, et al. Do bupropion SR and sertraline differ in their effects on anxiety in depressed patients? J Clin Psychiatry 2001; 62:776.
- Papakostas GI, Trivedi MH, Alpert JE, et al. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of individual patient data from 10 double-blind, randomized clinical trials. J Psychiatr Res 2008; 42:134.
- Papakostas GI, Stahl SM, Krishen A, et al. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies. J Clin Psychiatry 2008; 69:1287.
- Bystritsky A, Kerwin L, Feusner JD, Vapnik T. A pilot controlled trial of bupropion XL versus escitalopram in generalized anxiety disorder. Psychopharmacol Bull 2008; 41:46.
- Goodwin FK. Predictors of antidepressant response. Bull Menninger Clin 1993; 57:146.
- Leuchter AF, Cook IA, Hunter AM, Korb AS. A new paradigm for the prediction of antidepressant treatment response. Dialogues Clin Neurosci 2009; 11:435.
- Thase ME, Friedman ES, Biggs MM, et al. Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report. Am J Psychiatry 2007; 164:739.
- Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry 2006; 163:28.
- Stahl S. Anxiolytics and Sedative-Hypnotics. In: Essential Psychopharmacology; Neuroscientific Basis and Practical Applications, 2nd ed, Cambridge University Press, Cambridge 2000.
- Pollack MH, Matthews J, Scott EL. Gabapentin as a potential treatment for anxiety disorders. Am J Psychiatry 1998; 155:992.
- Pande AC, Davidson JR, Jefferson JW, et al. Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol 1999; 19:341.
- Van Ameringen M, Mancini C. Pharmacotherapy of social anxiety disorder at the turn of the millennium. Psychiatr Clin North Am 2001; 24:783.
- Pande AC, Pollack MH, Crockatt J, et al. Placebo-controlled study of gabapentin treatment of panic disorder. J Clin Psychopharmacol 2000; 20:467.
- British National Formulary (BNF) 65. ISBN 9780857110848., Pharmaceutical Press, London 2013. p.247.
- Mavissakalian M, Perel J, Bowler K, Dealy R. Trazodone in the treatment of panic disorder and agoraphobia with panic attacks. Am J Psychiatry 1987; 144:785.
- Prasad A. Efficacy of trazodone as an anti obsessional agent. Pharmacol Biochem Behav 1985; 22:347.
- Carroll BT, Kathol RG, Noyes R Jr, et al. Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale. Gen Hosp Psychiatry 1993; 15:69.
- CLINICAL MANIFESTATIONS
- DIFFERENTIAL DIAGNOSIS
- Adjustment disorder with anxious features
- Generalized anxiety disorder
- Panic disorder
- Posttraumatic stress disorder
- TREATMENT APPROACH
- Complementary therapies
- Lifestyle factors
- - Benzodiazepines
- Choice of agent and dosing
- Side effects
- - Selective serotonin reuptake inhibitors
- Alternative agents
- Choosing an antidepressant agent
- - Combination therapy
- Alternative agents
- Indications for referral to a mental health specialist
- SUMMARY AND RECOMMENDATIONS