Abstract
BackgroundAnxiety adversely affects quality of life and is common in adults with advanced life-limiting disease. There are no UK-wide guidelines on the assessment and management of anxiety in this specific population and there is little evidence regarding drug treatments. This study aimed to explore how palliative care physicians assess and manage anxiety in their patients, and to identify barriers encountered.MethodsA cross-sectional survey was undertaken of all physicians working in specialist palliative care in the UK who were members of the Association for Palliative Medicine. This was conducted in February 2014 using an online questionnaire.ResultsThe response rate was 23% (230/980) and 61% of respondents were consultants. Most did not use tools to screen for anxiety (87%) and almost all used the clinical interview to diagnose anxiety (99%). Only 8% used psychiatric criteria. Most physicians reported difficulties managing anxiety (93%). Only 33% thought they had adequate training in this area. Most had difficulty accessing psychological and/or psychiatric services (71%, 64% respectively). The majority used a combination of pharmacological and non-pharmacological treatments for anxiety. The most frequently prescribed first-line medications for patients with a prognosis of days to weeks were benzodiazepines (93%), usually lorazepam. The use of benzodiazepines over antidepressants was statistically significant (p < 0.001). For patients with a prognosis of months, antidepressants were most frequently prescribed first-line (60%), significantly more than benzodiazepines (p < 0.001). However, benzodiazepine use was still common in this prognostic group with 47% prescribing it first-line, sometimes in combination with an antidepressant.ConclusionThis is the first national survey on the assessment and management of anxiety in palliative care. Findings demonstrate the infrequent use of screening tools, variation in prescribing practice, potentially inappropriate use of benzodiazepines for patients with a prognosis of months, training gaps and poor access to psychological and psychiatric services in the UK. This highlights the need for formal training, further research into the pharmacological management of anxiety in this population and evidence-based national guidance to support clinical decision-making and service development.
Highlights
Anxiety adversely affects quality of life and is common in adults with advanced life-limiting disease
Considering grade of respondents in relation to the estimated total UK specialist palliative care physician workforce [40], there was a similar over-representation of more senior physicians and under-representation of trainees
Many respondents reported initiatives within their own services that had improved their clinical management of anxiety, or suggested changes they felt would address current challenges. These included additional training for themselves, having in-house staff cognitive behavioural therapy (CBT) trained, employing a psychologist or psychiatrist part-time to review patients and upskill the team, developing relationships and service level agreements with local psychological and psychiatric services, and the creation of national guidelines. This survey demonstrates that the majority of palliative care physicians find anxiety difficult to manage, it is so common in their patient population
Summary
Anxiety adversely affects quality of life and is common in adults with advanced life-limiting disease. Anxiety is common in adults with advanced life-limiting disease, adversely affecting quality of life, social relationships and daily functioning at a critical time [1, 2]. It impairs the individual’s ability to cope with their illness, erodes their trust in physicians, reduces treatment compliance and makes physical symptoms more difficult to manage [1,2,3]. It can be difficult to apply the strict criteria for specific anxiety disorders to patients with advanced life-limiting disease, they experience symptoms of anxiety that cause significant distress or functional impairment [12]. A broad definition of anxiety, incorporating all these anxiety states, is most relevant and practical in the palliative care clinical setting
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