Eliza M. Park

Parenting concerns, quality of life, and psychological distress in patients with advanced cancer

Parents with life‐limiting illness anticipate the loss of their parental role and the long‐term consequences of their illness on their children. The purpose of this study was to examine relationships between parenting concerns, quality of life (QOL), and symptoms of depression and anxiety in parents with advanced cancer who have dependent children.

Parenting while living with advanced cancer: A qualitative study:

Background: Patients with advanced cancer who have dependent children are an important population with a life-limiting illness and high levels of psychological distress. Few studies have addressed the experience of being a parent with advanced cancer and their potential palliative needs. Aim: To describe the experience of living with advanced cancer as a parent, including illness experience, parental concerns, and treatment decision making and to explore whether these experiences differ by their functional status. Design: We conducted a cross-sectional, qualitative study using in-depth, semi-structured interviews. Data were analyzed using thematic content analysis. Setting and participants: A total of 42 participants with metastatic cancer and with at least one child under the age of 18 years were recruited from a comprehensive cancer center. 25 participants were rated as having high functional status (the Eastern Cooperative Oncology Group (ECOG) Performance Status Scale = 0–1) and 17 with low functional status (ECOG=2–4). Results: We identified four themes regarding the experience of being a parent with advanced cancer: (1) parental concerns about the impact of their illness and death on their children, (2) “missing out” and losses of parental role and responsibilities, (3) maintaining parental responsibilities despite life-limiting illness, and (4) parental identity influencing decision making about treatment. Parental functional status influenced not only physical responsibilities but also intensified parenting psychological concerns. Conclusion: Parents with metastatic cancer may have unique palliative care needs as they experience parenting concerns while managing the psychological and physical demands of advanced cancer.

Overlooked and underserved: Widowed fathers with dependent-age children

OBJECTIVE Widowed fathers and their children are at heightened risk for poor coping and maladaptive psychosocial outcomes. This exploratory study is the first to explicitly examine the psychological characteristics of this population of fathers. METHOD Some 259 fathers (mean age = 46.81; 90% Caucasian) with dependent-age children and whose wives had died from cancer within the previous five years completed a web-based survey that consisted of demographic questions, the Center for Epidemiologic Studies Depression Scale (CES-D), the Texas Inventory of Grief-Revised (TRIG-R), the Psychological Adaptation Scale (PAS), the Kansas Parental Satisfaction Scale (KPSS), and items assessing perceived parental efficacy. RESULTS Fathers were found to have elevated depressive (CES-D mean = 22.6) and grief (TRIG-R mean = 70.3) symptomatology, low adaptation (PAS mean = 3.2), and high levels of stress related to their parenting role. They reported being satisfied with their parenting (KPSS mean = 15.8) and having met their own parental expectations. Multivariate analyses revealed an association between fathers age and depression (p = <0.01), with younger fathers reporting greater depressive symptoms. Psychological adaptation was positively correlated with being in a romantic relationship (p = 0.02) and age of oldest child (p = 0.02). SIGNIFICANCE OF RESULTS The results of our exploratory study suggest that, while widowed fathers perceive themselves as meeting their parental responsibilities, it comes at a substantial psychological cost, with particularly high stress related to being a sole parent. These findings may help guide interventions for this neglected population and underscore the importance of developing targeted therapies and research protocols to address their needs.

Evaluation and Management of Opioid Dependence in Pregnancy

BACKGROUND Opioid use disorders are a growing public health problem in the United States. Most women who are opioid-dependent are of childbearing age, and management of opioid dependence during pregnancy poses unique challenges. Assessment includes evaluation for addiction, withdrawal syndromes, and comorbid psychiatric diagnoses. Consultation-liaison (C-L) psychiatrists may also be involved in acute pain management, perinatal medication management, buprenorphine induction, and stabilization. For the past four decades, the standard of care has included methadone maintenance, but the increasing use of buprenorphine creates new treatment issues and opportunities. OBJECTIVE To educate C-L psychiatrists in emergency and obstetrical settings about the appropriate approach toward the evaluation and basic management of women with opioid dependence in pregnancy. METHOD The authors reviewed the consensus literature and all new treatment options on opioid dependence during pregnancy. DISCUSSION In this review, the authors summarize known and emerging management strategies for opioid dependence in pregnancy pertinent to C-L psychiatrists.

End-of-life experiences of mothers with advanced cancer: perspectives of widowed fathers.

Objective Despite the importance of parenting-related responsibilities for adult patients with terminal illnesses who have dependent children, little is known about the psychological concerns of dying parents and their families at the end of life (EOL). The aim of this study was to elicit widowed fathers’ perspectives on how parental status may have influenced the EOL experiences of mothers with advanced cancer. Subjects 344 men identified themselves through an open-access educational website as widowed fathers who had lost a spouse to cancer and were raising dependent children. Methods Participants completed a web-based survey about their wifes EOL experience and cancer history, and their own depression (Center for Epidemiologic Studies Depression Scale, CES-D) and bereavement (Texas Revised Inventory of Grief, TRIG) symptoms. Descriptive statistics, Fishers exact tests, and linear regression modelling were used to evaluate relationships between variables. Results According to fathers, 38% of mothers had not said goodbye to their children before death and 26% were not at all ‘at peace with dying.’ Ninety per cent of widowed fathers reported that their spouse was worried about the strain on their children at the EOL. Fathers who reported clearer prognostic communication between wife and physician had lower CES-D and TRIG scores. Conclusions To improve EOL care for seriously ill patients and their families, we must understand the concerns of parents with dependent children. These data underscore the importance of parenting-related worries in this population and the need for additional clinical and research programmes devoted to addressing these issues.

Living With Advanced Cancer Unmet Survivorship Needs

Most cancer survivorship initiatives are designed for patients whose treatment is intended to be curative. For patients living with advanced cancer, in contrast, survivorship research efforts and programs are far less common. This neglected aspect of cancer survivorship requires particular emphasis on active symptom management and clarification of goals of care.

An exploratory study of end-of-life prognostic communication needs as reported by widowed fathers due to cancer

Effective physician communication about prognosis is a critical aspect of quality care for families affected by terminal illness. This is particularly important for spousal caregivers of terminally ill parents of dependent children, who may have unique needs for communication about anticipated death. The objective of this study was to explore end‐of‐life prognostic communication experiences reported by bereaved fathers whose wives died from cancer.

Conducting an antidepressant clinical trial in oncology: challenges and strategies to address them

OBJECTIVE The aim of this report is to discuss the design of an antidepressant clinical trial and discuss the challenges and potential solutions to these challenges to successful recruitment of oncology patients for psychopharmacology trials. METHOD We utilize meeting minutes and investigator discussions to identify the modifiable and nonmodifiable variables that affected successful subject recruitment for this study. RESULTS No subjects were enrolled in our placebo-controlled antidepressant trial. After study modification to remove the placebo arm, we enrolled 21 subjects with depression and cancer. We identified the following recruitment difficulties during the study: diagnostic ambiguity in patients with depression and cancer, lowered subject retention in a medically ill population, patient reluctance to enroll in placebo-controlled studies and lack of a standardized referral processes for antidepressant studies in oncology at our institution. CONCLUSION Our experience provides guidance on specific factors that future clinicians and researchers can consider when implementing psychopharmacologic trials in the medically ill.

Acute Mania Associated With Levetiracetam Treatment

Levetiracetamisanovelantiepilepticdrugusedfor the treatment of partial and generalized epilepsy. Its mechanism of action is unclear, though it is thought to bind to a presynaptic vesicle protein that ultimately reduces the synaptic release of glutamate, impeding conduction of epileptic action potentials across the synapse. 1 Levetiracetam is frequently used owing to its ease of oral administration, excellent bioavailability, and low rate of drug interactions as it is not metabolized by the liver or bound significantly to serum proteins. 2,3 Adverse cognitive effects are atypical; however, adverse effects in the central nervous system (CNS) are relatively common, with behavioral symptoms occurring in up to 16% of patients in randomized controlled trials. 4 Frequently reported behavioral symptoms include depression, hostility, agitation, emotional lability, anger, nervousness, and depersonalization. Nonbehavioral CNS effects include sedation,headache,andasthenia. 5 Psychosisisinfrequently associated with levetiracetam, occurring in approximately 1% of patients, but well described in multiple case reports. 6,7 Researchers have explored the use of levetiracetam as a mood stabilizer for treatment of both depressive and manic phases of bipolar disorder with mixed results. 8–10 Despite the known association between levetiracetam and aggression and irritability, there are no reported cases in the literature of levetiracetam precipitating manic symptoms. In the following case report, we describe the acute onset of mania after levetiracetam therapy in a woman with no history of mania or hypomania.

Psychosomatic Medicine Training as a Bridge to Practice: Training and Professional Practice Patterns of Early Career Psychosomatic Medicine Specialists

BACKGROUND The number of interested candidates for psychosomatic medicine (PM) training programs has not matched the growing need for psychiatrists trained to care for complex medically ill patients. The reasons for this lack of growth may be found in the experience of new entrants into the subspecialty. OBJECTIVE To investigate this issue, we conducted a survey of early career psychiatrists (ECPs) practicing PM to identify the personal and professional characteristics of ECP PM specialists and to examine the relevance of PM training to professional practice. METHODS ECPs who attended the 2012 Academy of Psychosomatic Medicine annual meeting or who were registered members of the Academy of Psychosomatic Medicine completed a survey on training and work experiences. Decisional factors associated with pursuit of subspecialty fellowship education and professional practice patterns were identified using descriptive statistics and chi-square tests. RESULTS A total of 102 ECPs completed the survey. Of the respondents, 67 (67%) had completed a PM fellowship. Motivating factors for pursuing fellowship training included (1) obtaining additional clinical training, (2) developing a special interest in PM training, and (3) improving job candidacy. Overall, 80% of ECPs desired inpatient consultation-liaison positions at the time of fellowship graduation. Overall, 22% reported difficulty in obtaining employment in PM after training. Chi-square tests between subjects who pursued a PM fellowship and those who did not proved nonsignificant. CONCLUSIONS PM fellowship training remains relevant and important to ECPs in this sample. The survey results can be used to shape institutional and professional supports to better meet early career transition needs for PM psychiatrists.