The June issue of ACLP News described psychological stress from routine cancer care in an article C-L Psychiatrists Should Know About Stem Cell Transplant Side-Effects. Here researchers provide further insight into psychological considerations in Hematopoietic Stem Cell Transplantation (HSCT).
Life-saving intervention lacks psychiatric comorbidity assessment tools and strategies
HSCT has become a life-saving treatment for some patients with hematologic malignancies; however, it is associated with a high prevalence of psychological distress and psychiatric comorbidities impact quality of life, function, and recovery.
“A comprehensive diagnostic approach that uncovers both physical and psychological symptoms, with a nuanced understanding of how hematologic malignancies and the HSCT naturally impact these symptoms, is essential to inform psychiatric diagnosis and treatment strategies,” say Hermioni Lokko Amonoo, MD, MPP, and colleagues, at the Dana-Farber Cancer Institute.
“Early identification of patient vulnerabilities to psychiatric comorbidities can also facilitate timely diagnostic assessment and treatment.”
Both pharmacological and psychosocial interventions have been successfully used to treat psychosocial challenges in HSCT, although research and evidence has trailed behind clinical practice, say the researchers.
“Considering the complex nature of HSCT and the intensive, prolonged recovery, further research is needed to understand the optimal psychiatric assessment tools, and treatment strategies needed to address psychiatric comorbidities in this growing and important population.”
In their paper, the researchers outline the HSCT hospitalization phases and discuss common psychiatric challenges, such as depression, delirium, and posttraumatic stress reactions that accompany HSCT. They discuss an approach to psychiatric consultations during the HSCT hospitalization and provide practical interventions for managing psychological psychiatric challenges.
“Considering the complex nature of HSCT and the intensive, prolonged recovery, further research is needed to understand the optimal psychiatric assessment tools and treatment strategies”
—Dr. Hermioni Lokko Amonoo
Background
More than 50,000 HSCTs are performed worldwide each year. HSCT is usually reserved for patients with life-threatening diseases to provide life-prolonging or curative treatment. Advances in transplantation medicine, including improvement in supportive care and infection management, use of peripheral blood stem cells from unrelated or alternative donors, and improved posttransplant care, have resulted in reduced morbidity and mortality from HSCT.
Although most patients who undergo HSCT do not have formal psychiatric disorders, a high prevalence of psychological distress—including depressive symptoms (approximately 35%), delirium (approximately 35%), and posttraumatic stress disorder symptoms (approximately 20%)—is reported by patients and observed by clinicians.
Pretransplant considerations
Most patients are considered for HSCT after an extensive oncologic evaluation. A pretransplant psychiatric evaluation serves as a baseline for the patient’s mental health and prepares patients for HSCT.
Although there is no standard mental health evaluation for this process, say the researchers, a detailed review of oncologic, medical, psychiatric, and family psychiatric history provides insights into patients’ risk for psychiatric disorders, either in relation to, or irrespective of, HSCT status.
Pertinent risk factors include substance abuse history and neuropsychiatric limitations (e.g., memory problems) that could interfere with the HSCT follow-up.
“HSCT centers are not widespread and most patients travel a long distance from their supportive communities for an extended period to undergo treatment,” say the researchers. “Hence, a comprehensive evaluation of patients’ expectations and social supports is imperative to understanding potential psychosocial barriers to good coping.”
Hospitalization phases
HSCT hospitalization consists of:
The paper gives a description of each phase.
The second phase is the stem cell infusion (commonly referred to as Day Zero). Depending on response to the conditioning regimen, a small proportion of patients will go into transplant with significant physical symptoms that impact their level of psychological distress.
The combination of increased physical signs and symptoms (e.g., nausea, anorexia, pain, diarrhea, fever, hair loss) and other medical illnesses can result in significant psychological distress, especially during the engraftment phase.
The posttransplant period is divided into two phases: the acute posttransplant phase (the first 100 days), and the chronic posttransplant phase (>100 days and up to several years).
Routine follow-up care post-HSCT involves twice-weekly outpatient visits for several weeks. The continued isolation (where patients are restricted from contact with large numbers of people or crowds) for the recovery continues into the first 100 days of the recovery.
“For patients who usually maintain an active lifestyle at baseline, a significant amount of emotional distress during this phase of the recovery is common as they cannot engage in vigorous or outdoor activities that were previously considered meaningful or contributed positively to quality of life,” say the researchers.
Common manifestations
The researchers comment on psychological challenges observed in HSCT patients at different stages of the process and delineate where normal psychological reactions transition to psychiatric disorders. They cover:
Anxiety: “Some patients worry about their response to the transplant, their quality of life in recovery while in isolation, and their ability to manage potential complications in recovery, especially if they are far from home and social support.”
Posttraumatic stress reactions: “Life-threatening medical conditions and their treatment, especially in the cancer population have been identified as stressors that can precipitate PTSD… HSCT patients can relive cancer and treatment experience with nightmares, flashbacks, or continuous thoughts about the HSCT process.”
Sleep disruption: “Sleep disturbances are common among HSCT patients, with more than 50% reporting sleep disruption before the transplant, up to 82% experiencing moderate-to-severe sleep disruption during the transplant hospitalization, and 43% posttransplant.”
Depression: “Depression observed in HSCT may also develop years after the transplant with the prevalence increasing until five years posttransplant.”
Delirium and other neurocognitive dysfunction: “As in most cancer patients, delirium is often unrecognized and undertreated in the HSCT population… Neurocognitive dysfunction in HSCT survivors is a major cause of morbidity and mortality.”
Adjustment reactions: “The isolation and adjustment to a variety of restrictions (including a neutropenic transplant diet, social isolation, or avoidance of large crowds) adds to the emotional challenge of the engraftment days.”
Demoralization: “Engraftment days predispose people to demoralization due to the length of isolation and hospitalization, as well as the increased prevalence of medical comorbidity. Demoralized patients feel disempowered and helpless.”
The researchers discuss the primary goal of psychiatric consults during HSCT hospitalization; vulnerability factors for psychological challenges among different patients; medication and treatment factors; and both pharmacological and nonpharmacological interventions.
“C-L psychiatrists are uniquely positioned to work with both oncological and HSCT clinicians in the management of these psychiatric comorbidities,” say the researchers.
The full text of Psychological Considerations in Hematopoietic Stem Cell Transplantation in the July/August issue ofPsychosomatics is here.