Submitted by by Kari Isaak, RN, BSN
Bone and Marrow Transplant (BMT) is a five step treatment process: screening, collecting, conditioning, infusion, and engraftment. Bone and marrow transplant treatment is very aggressive that creates significant physical, social, psychological, and emotional stress. During the treatment process, many BMT recipients experience and display a wide array of psychosocial disorders including distress, anxiety, and depression. The way an individual experiences and copes with the distress, anxiety, and depression contributes to the physiological, psychological, and psychosocial outcomes of BMT treatment. The paper will discuss how distress and depression impact the physiological, psychological, and psychosocial outcomes with the BMT population, explain the Transactional Model of Stress and Coping theoretical framework, review literature findings evaluating the relationship between social support, coping, distress and depression, and discuss depression symptom interventions.
Bone marrow is a soft, spongy tissue found inside bones where all blood cells are produced. Every type blood cell in marrow begins as a hematopoietic stem cell or “parent cell”. The stem cells form and differentiate into leukocytes, erythrocytes, and platelets. Leukocytes are further differentiated into neutrophils, eosinophils, basophils, monocytes, and lymphocytes. (National Bone Marrow Transplant Link (NBMTL), 2006).Various diseases and conditions can cause bone marrow malfunction to produce immature or defective blood cells. Diseases examples, but not limited to, include POEMS, acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), lymphoma, aplastic anemia, primary amyloidosis, multiple myeloma, myeloproliferative disorders, and solid tumors. Certain side effects of high doses of chemotherapy and radiation therapy may cause bone marrow malfunction. (Autologous Blood and Marrow Transplant, Mayo Foundation for Medical Education & Research (MFMER), 2008)
Stem cells sources are found in the bone marrow, peripheral blood, and placenta. BMT is used as a treatment for the diseases and cancers causing bone marrow malfunction. Initially, the first source of stem cells was collected at the hip bone performed through a surgical procedure called a bone marrow biopsy. The discovery of hematopoietic stem cells in the peripheral blood has lead to the major source of stem cells rather than the bone marrow. The collection of peripheral blood stem cells is referred to as hematopoietic stem cell transplant (HSCT). The stem cell donor determines which type of transplant will be performed. An autologus transplant receives own stem cells. An allogeneic-related transplant receives stem cells from a genetically-matched family member. An allogeneic-unrelated transplant receives stem cells from an unrelated person. A syngeneic transplant receives stem cells from an identical twin. (NBMTL, 2006).
Bone and marrow transplantation is completed through a five step process: screening, collecting, conditioning, infusion, and engraftment. The screening phase includes a comprehensive medical history, physical exam, psychosocial evaluation. Additional testing in the phase includes evaluating the function of vital organs (x-rays, CT, PET scan, bone marrow aspiration & biopsy). The collection phase is where donor receives stem cells are collected and harvested from patient or donor via bone marrow aspiration or peripheral blood stem cell aphaeresis. The conditioning phase refers to when chemotherapy and /or radiation therapy administered to patient to destroy cancer cells. The infusion phase includes administering the harvested stem cells which travel to bone marrow spaces making new blood cells. The infusion period usually last three weeks which during this time the transplant patient has a limited immune system. Engraftment phase occurs when the transplanted stem cells begin to produce normal blood cells that can be detected in the blood. (MFMER, 2008).
Bone and marrow transplant treatment is very aggressive that creates significant physical, social, psychological, and emotional stress. The physical consequences from treatment can include fever, fatigue, nausea, vomiting, anemia, appetite changes, constipation, diarrhea, hair loss, infection, memory changes, mouth sores, and pain. Additionally, BMT treatment can exacerbate stressors including prolonged hospitalization, isolation, change in appearance, fear of transplant failure, and death. During the treatment process, many BMT recipients experience and display a wide array of psychological disorders including distress, anxiety, and depression. The way an individual experiences and copes with the distress, anxiety, and depression contributes to the physiological, psychological, and psychosocial outcomes of BMT treatment.
The Transactional Model of Stress and Coping is a theoretical framework for evaluating coping progression with stressful situations and events. During a stressful event, a person evaluates the level of the threat (primary appraisal) and the ability to cope with the threat as positive or negative (secondary appraisal). Primary appraisal is the person’s judgment of the event as stressful, positive, controllable, challenging, or irrelevant. Secondary appraisal follows as the person perceives and assesses their coping resources and options to address the stressful event as either positive or negative. Key examples of secondary appraisals are perceived ability to change the situation, perceived ability to manage emotional reactions to the threat, and expectations about the effectiveness on one’s coping resources. The emotional and functional effects of primary and secondary appraisals are mediated by an individual’s coping strategy. A person may be more likely to use disengaging coping strategies if the stressful event is perceived as threatening and uncontrollable. Examples of disengaging coping strategies include cognitive avoidance, behavioral avoidance, distraction, distancing, and denial. A person may be more likely to use engaging coping strategies if the stressful event is perceived as controllable and a person have favorable beliefs about self-efficiency. Examples of engaging coping strategies include active coping, information seeking, planning problem solving, and use of social support. Coping outcomes change over time and across situations (Wenzel, Glanz, & Lerman, 2002).
The National Comprehensive Caner Network (NCCN) Clinical Practice Guidelines in Oncology (2010) defines distress in cancer as:
a multifactorial unpleasant emotional experience of a psychological, social, and/or spiritual nature that interferes with the ability to cope effectively with cancer, its physical symptoms and its treatment. It extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis. (p. DIS-2).
High distress levels has been associated with decreased adherence to chemotherapy regimens (Newell, Sanson-Fisher, & Savolainen, 2002), increased length of hospital stay (Preito et al., 2002), slower recover and increased physical limitation (Syrjala et al., 2004) decreased quality of life (Andrykowski et al., 2005; Molassiotis, Boughton, Burgoyne, & VanDen Akker, 1995), interferes with ability to perform daily activities (Molassiotis et. al., 1995), decreased life satisfaction (Sherman, Simonton, Latif, Plante, Anaissie, 2009), changes in body image, changes in personal goals, loss of independence, and decreased rates of survival (Colon, Callies, Popkin, & McGlave, 1991; Hoodin, Kalbfleisch, Thorton, & Ratanatharathorn, 2004; Rodrigue, Pearman, & Moreb, 2000).
The mounting evidence state anxiety and depression has considerable consequences in the months and years following transplantation. Prieto et al. (2002) performed 1,062 psychiatric assessments of hospitalized stem cell transplantation patients to discover an overall psychiatric disorder prevalence rate was 44.1% and an overall prevalence rate for any mood, anxiety or adjustment disorder was 42.3%. The data indicates patients receiving stem cell transplantation have a high psychiatric morbidity and an association with longer length of stays, underscoring the need for early recognition and effective treatment. Fife et al. (2000) completed a data analysis of 101 BMT patients to reveal the period of initial hospitalization as being the most stressful and the highest degrees of anxiety, depression, anger and uncertainty. Illescas-Rico, Amaya-Ayala, Jimènez-López, Caballero-Méndez, & González-Llaven (2002) discovered allogeneic transplants verses autogeneic transplants had depression occur more frequently immediately following post-transplantation. Lee et al. (2005) found 44% post-transplant patients reported symptoms of depression, anxiety or post traumatic disorder. Sherman, Simonton, Latif, Plante, & Anaissie et al. (2009) found elevated cancer-related distress, higher level of anxiety and depression at stem cell collection and post-transplantation. The strong association between health outcomes and negative affect for the BMT patient has several important implications for healthcare professionals including psychological/psychiatric assessment prior to BMT treatment.
Psychological distress/depression evaluation and screening leads to early recognition, which in turn improves medical management (Carlson & Bultz, 2003; NCCN, 2010). The importance to evaluate the predictors of distress, anxiety, and depression in patients undergoing a stem cell transplant has shown depression has an association with increased stem cell transplant hospitalization and mortality (Andrykowski et al., 2004; Colon et al., 1991; Hoodin et al., 2004; Frick, Motzke, Fischer, Busch, & Bumeder, 2005; Prieto et al, 2002; Rodrigue, Pearman, & Moreb, 2000) Lee et al. (2005) evaluated the feasibility of screening for psychological distress prior stem cell transplant to find elevated levels of anxiety and /or depression were detected in 55% of those providing pre-transplant assessments and were associated with compromised quality of life. The study concluded that pre-transplant distress appears to highly predict distress post transplant and is a feasible marker to target screening and intervention programs. Colon et al. (1991) findings indicated that a depressed mood before BMT may represent a negative marker for patient outcomes. NCCN reports less than 10% of oncology patients receive psychosocial therapy due to under recognition of patient’s psychological needs (Lee et al, 2005; NCCN guidelines, 2010). Patients may not report signs of distress due to fear being a burden on busy clinical staff, feel is a sign of weakness, or the belief distress cannot be helped (Lee et al., 2005) Patients at higher risk for BMT related complications were more likely to report psychological distress (Rodrique et al., 2000) Assessing and identifying individuals at high-risk before transplantation could enhance psychological interventions, resource distribution, and survival (Hoodin et al., 2004). An informal psychological distress assessment performed by a healthcare professional that indicates a high level of distress should be referred to a psychologist or psychiatrist for formal assessment (Trask et al., 2002). The psychological assessment should be a routine component of the pre-admission process. Only 50% of stem cell transplant centers implement a psychological/psychiatric assessment or monitoring program prior to BMT treatment (Lee et al., 2005).
Physicians, registered nurses, and mental health professionals are key agents to assess depression/distress and intervene appropriately to provide physiological, psychological, and psychosocial care for the BMT population. Several screening tools have been found to be effective in identifying distress and depression among BMT patients. The Distress Thermometer is an initial screening tool which serves as a single question to identify distress on a 1-10 scale. The distress is accompanied by 35 problem list prompting patient to identify their problems in five different categories: practical, family, emotional, spiritual/religious, and physical (NCCN, 2010). Ransom, Jacobsen, & Booth-Jones (2006) validated and found the tool useful for measuring distress in BMT patients. Scores greater than four or higher suggested a level of distress to have clinical significance. Additional tools used to assess distress and depression include the Profile of Mood Scale (POMS), Symptom Distress Scale (SDS), Beck Inventory of Depression (BID), Hospital Anxiety and Depression Scale (HADS), NCCN Distress Thermometer, Zung Depression Inventory, Psychosocial Levels System (PLS), and Center for Epidemiological Studies-Depression Scale (CES-D).
Psychosocial and coping status assessment is a continuation of the integral treatment of BMT treatment. Assessment of psychological and coping status prior to BMT treatment has great importance in anticipating difficulties and preventing emotional crises. Molassiotis (1999) found 25% patients had psychological disturbances and impaired coping mechanisms during marrow transplantation. Additionally, impaired coping mechanisms identified prior to BMT treatment were denial, lack of clarity, and ambiance over treatment. The study found positive coping mechanisms during hospitalization were hope, directing attention, maintaining control over situation, and acceptance. Ineffective verses effective coping mechanisms can have important influences on psychological and physical outcomes. Previous studies have shown the importance of coping assessment with BMT patient survival and positive health status (Andrykowski et al., 2005; Meyers et al., 1994; Molassiotis, 1999; Wells, Booth-Jones, & Jacobsen, 2009). The assessment of coping styles enables professionals to obtain the optimum level of adaptation to treatment and identifying and reinforcement specific coping behaviors. The anticipation of specific psychosocial stressors may occur at various points in the treatment process and to identify factors may contribute to the exacerbation of BMT distress. (Fife et al., 2000) Coping assessment and evaluation should be performed after transplant and hospitalization as the patients emotional and physical needs change (Wells et al., 2009). Educating effective coping and behavioral strategies/programs can lower the incidence of distress and depression, improve coping, and enhance psychological and physical well-being among the BMT patient population.
Psychosocial variables assessed before transplant have been shown to predict both psychosocial and physical outcomes (Goetzmann et al., 2007). Social support has been an impact on survival rates following stem cell transplant. Patients scoring a problematic social support prior to stem cell transplant showed a correspondence with poorer survival (Frick et al., 2005) Patients with a high level of perceived social support had improved survival (Colon et al, 1991) and higher quality of life (Frick et al., 2005; Rodrigue et al, 2000) The relation between social support and positive health outcomes provides the emphasizes the importance of social support assessment.
NCCN has clinical practice oncology guidelines, pathways, and protocols for recognizing, evaluating, and treating psychological disturbances including distress, delirium, mood disorders, adjustment disorders, anxiety, and personality disorders. The management of distress/depression should be based on a detailed assessment of individual’s emotional, social, and psychological well-being with individualized interventions. The individualized interventions may utilize several modalities including psychosocial therapy and pharmacologic medication for symptom relief.
Psychosocial therapy includes, but not limited to, supportive psychotherapy, cognitive-behavioral therapy, problem-solving techniques, and mindful-based therapy. Psychosocial therapy has been found to be effective for cancer patients by improving the overall quality of life and reducing distress (Holland & Alici, 2010; Jacobsen, 2009). Patients who received professional psychosocial therapy demonstrated significantly lower mood disturbance during BMT treatment (Molassiotis, VanDen Akker, Milligan, Goldman, & Boughton, 1996). Horton-Deutsch, Day, Haight, & Babin-Nelson (2007) conducted a pilot study to determine the acceptability and feasibility using mindfulness based approaches for patients undergoing BMT to find participants had a more positive affect after performing mindfulness interventions while experiencing an increase in symptoms, nausea, and appetite problems. Gabriel et al. (2001) conducted an art therapy program, The Creative Journey, for BMT patients to find art therapy strengthened positive thoughts, help resolve distressing emotional conflicts, deepened awareness of spiritual issues, and facilitated communication with family. Although, no additional studies were found using psychosocial interventions in the BMT patient population all recommended further research in psychosocial therapy.
Bone marrow transplant patients are vulnerable to distress and depression at all stages in the process of treatment. The management of distress/depression may benefit from a pharmacologic medication (antidepressant). Williams & Dale (2006) reviewed six studies for the efficacy of antidepressant intervention and found evidence to support antidepressants are effective in the reduction depression/depressing symptom in cancer patients. The first line of depression treatment has been the usage of selective serotonin reuptake inhibitors due to their efficacious and well tolerance. Several antidepressants classes are available including tricyclics, serotonin-norephinephrine reuptake inhibitors, and norephinephrine-dopamine reuptake inhibitors. The antidepressant selected should be based on the primary symptoms, patient’s prognosis, co-morbid conditions, potential side effects and drug-drug interactions (Holland & Alici, 2010).
Psychosocial therapy and pharmacologic medication may be necessary to help the patient deal with the stressful events associated with BMT pre-transplant, during hospitalization, and after discharge. Psychosocial therapy alone or in combination with a pharmacologic medication has been utilized to successfully to decrease depressive symptoms in cancer patients (Holland & Alici, 2010). Randomized controlled trials (RCT) and more adequately powered research studies are needed to explicitly test the efficiency of pharmacotherapy and psychotherapy in managing distress/depression among BMT patient population (Jacobsen & Jim, 2008; Pirl, 2004; Williams & Dale, 2006)
A detailed assessment of BMT recipient’s emotional, social, and psychological well-being before BMT is necessary to provide optimal, holistic care. Distress and depression should be recognized, monitored, documented and treated promptly during the BMT treatment. BMT patients need to be screened at their pre-transplant appointment, at appropriate intervals, and as clinically indicated during the BMT process. Distress and depression should be recognized, monitored, documented and treated promptly during the BMT process to ensure positive patient outcomes.
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