2010NCCN 忧郁治疗指南

Continue NCCN Clinical Practice Guidelines in Oncology™ Distress Management V.1.2010 www.nccn.org Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management NCCN Distress Management Panel Members Jimmie C. Holland, MD/Chair Memorial Sloan-Kettering Cancer Center Caryl D. Fulcher, RN, MSN, CS Duke Comprehensive Cancer Center � � � � � � � Barbara Andersen, PhD The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute William S. Breitbart, MD Memorial Sloan-Kettering Cancer Center Bruce Compas, Phd Vanderbilt-Ingram Cancer Center Moreen M. Dudley, MSW Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance Stewart Fleishman, MD Consultant Þ £ Matthew J. Loscalzo, MSW City of Hope Comprehensive Cancer Center Sharon Manne, PhD Fox Chase Cancer Center Randi McAllister-Black, PhD City of Hope Comprehensive Cancer Center Michelle B. Riba, MD, MS University of Michigan Comprehensive Cancer Center Kristin Roper, RN # Dana-Farber/Brigham and Women’s Cancer Center Alan D. Valentine, MD The University of Texas M. D. Anderson Cancer Center Lynne I. Wagner, PhD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Michael A. Zevon, PhD Roswell Park Cancer Institute £ � � � � � � * Donna B. Greenberg, MD Massachusetts General Hospital Cancer Center Carl B. Greiner, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Rev. George F. Handzo, MA, MDiv Consultant Laura Hoofring, MSN, APRN The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Paul B. Jacobsen, PhD H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida Sara J. Knight, PhD UCSF Comprehensive Cancer Center Kate Learson Consultant Michael H. Levy, MD, PhD Fox Chase Cancer Center � � � � Þ £ ¥ £ # † � � � Psychiatry, psychology, including health behavior Þ Internal medicine ‡ Hematology/Hematology oncology £ Supportive Care including Palliative, Pain management, Pastoral care and Oncology social work Bone Marrow Transplantation ¥ Patient advocacy † Medical oncology Neurology/neuro-oncology * Writing committee member # Nursing Continue NCCN Guidelines Panel Disclosures * * Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Table of Contents Key Terms: NCCN Distress Management Panel Members Summary of Guidelines Updates Distress (DIS-1) Definition of Distress in Cancer (DIS-2) Standards of Care for Distress Management (DIS-3) Overview of Evaluation and Treatment Process (DIS-4) Expected Distress Symptoms (DIS-5) Psychological/Psychiatric Treatment Guidelines (DIS-6) Social Work Services (DIS-18) Chaplaincy Services (DIS-19) Recommendations for Implementation of Standards and Guidelines (DIS-26) Institutional Evaluation of Standards of Care (DIS-27) For End of Life Issues, See the NCCN Palliative Care Guidelines For Cancer Pain, See the NCCN Cancer Pain Guidelines Guidelines Index Print the Distress Management Guideline � � � Distress Management Assessment Tool (DIS-A) Psychosocial Distress Patient Characteristics (DIS-B) These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2010. For help using these documents, please click here Discussion References Clinical Trials: Categories of Evidence and Consensus: NCCN All recommendations are Category 2A unless otherwise specified. See The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. NCCN To find clinical trials online at NCCN member institutions, click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Summary of the Guidelines Updates Summary of changes in the 1.2010 version of the Distress Management Guidelines from the 2.2009 version include: Throughout the Distress Management Guidelines, the terminology “Pastoral” was changed to “Chaplaincy”. First bullet: Changed to, “...documented, and treated promptly at all stages of disease and in all settings.” Fifth bullet: “Multidisciplinary institutional committees...” changed to “Interdisciplinary institutional committees...” (Also for DIS-26 and DIS-27) Sixth/Seventh bullet: “Pastoral caregivers” changed to “Certified chaplains”. Last bullet: Changed to “Quality of distress management programs/services should be...” Footnote “a”: “Nurse and clinical nurse specialist” changed to “Advanced practice clinicians”. Family Problems: The panel added “Ability to have children”. First column; Last bullet: After “Pain”, the panel added “Fatigue, sleep disorders, cognitive impairment.” “Spiritual evaluation” changed to “Spiritual assessment” throughout the Chaplaincy Service algorithms. Top pathway after “Severe depressive symptoms...” recommendation changed to “Refer to mental health professional for further assessment, intervention, and follow-up.” Second column: Recommendation changed to “Physician consultation to clarify treatment options and goals of care.” Top pathway; After “Conflict not resolved”: Recommendation changed to “Ethics/ consultation”. � � � � � � � � � � � � “Pastoral evaluation” changed to “Chaplaincy assessment”. � Palliative care ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) DIS-3 DIS-4 DIS-A DIS-8 DIS-19 DIS-20 DIS-22 DIS-24 UPDATES Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Term “distress” was chosen because: � � � It is more acceptable and less stigmatizing than “psychiatric,” “psychosocial,” or “emotional” Sounds “normal” and less embarrassing Can be defined and measured by self-report. “DISTRESS” Definition of Distress in Cancer (DIS-2) DIS-1 Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Distress is a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress 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. DEFINITION OF DISTRESS IN CANCER Standard of Care for Distress Management (DIS-3) DIS-2 Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. � � � � � � � � � � Distress should be recognized, monitored, documented, and treated promptly at all stages of disease and in all settings. Screening should identify the level and nature of the distress. All patients should be screened for distress at their initial visit, at appropriate intervals, and as clinically indicated especially with changes in disease status (ie, remission, recurrence, progression). Distress should be assessed and managed according to clinical practice guidelines. Interdisciplinary institutional committees should be formed to implement standards for distress management. Educational and training programs should be developed to ensure that health care professionals and certified chaplains have knowledge and skills in the assessment and management of distress. Licensed mental health professionals and certified chaplains experienced in psychosocial aspects of cancer should be readily available as staff members or by referral. Medical care contracts should include reimbursement for services provided by mental health professionals. Clinical health outcomes measurement should include assessment of the psychosocial domain (eg, quality of life and patient and family satisfaction). Patients, families, and treatment teams should be informed that management of distress is an integral part of total medical care and provided with appropriate information about psychosocial services in the treatment center and the community. Quality of distress management programs/services should be included in institutional continuous quality improvement (CQI) projects. � DIS-3 STANDARDS OF CARE FOR DISTRESS MANAGEMENT Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Brief screening for distress (DIS-A): Screening tool Problem list � � EVALUATION OVERVIEW OF EVALUATION AND TREATMENT PROCESS TREATMENT If necessary Referral Primary oncology team + resources available Mental health services b Social work services Chaplaincy services See Psychological/ Psychiatric treatment Guidelines (DIS-6) See Social Work Services (DIS-18) See Chaplaincy Services (DIS-19) Refer to NCCN Guidelines Table of Contents for Supportive Care Guidelines. a bPsychiatrist, psychologist, advanced practice clinicians, social worker and certified chaplain. See Psychosocial Distress Patient Characteristics (DIS-B). DIS-4 See Management of Expected Distress Symptoms (DIS-5) Clinical evidence of moderate to severe distress or score of 4 or more on screening tool ( )DIS-A Clinical evidence of mild distress or score of less than 4 on screening tool ( )DIS-A Clinical assessment by primary oncology team of oncologist, nurse, social worker for: � � � � � High risk patients Periods of vulnerability Risk factors for distress a � � Practical problems Family problems Spiritual/religous concerns Physical problems Unrelieved physical symptoms, treat as per disease specific or supportive care guidelines Follow-up and commun- ication with primary oncology team Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management DIS-5 EXPECTED DISTRESS SYMPTOMS INTERVENTIONS RE-EVALUATION � � Patients at increased risk of vulnerability to distress Signs and symptoms of normal fear and worry of the future and uncertainty a � � � � � � � � Concerns about illness Sadness about loss of usual health Anger, feeling out of control Poor sleep Poor appetite Poor concentration Preoccupation with thoughts of illness and death Disease or treatment side effects � � � � � � � � � � � Clarify diagnosis, treatment options and side effects Refer to appropriate patient education materials (eg, NCCN Treatment Summaries for Patients) Educate patient that points of transition may bring increased vulnerability to distress Acknowledge distress Build trust Ensure continuity of care Mobilize resources Consider medication to manage symptoms: Analgesics Anxiolytics Hypnotics Antidepressants Family support and counseling Relaxation, meditation, creative therapies (eg, art, dance, music) Exercise � � � � � � Be sure patient understands disease and treatment options Support groups and/or individual counseling ( ) See NCCN Adult Cancer Pain Guidelines Monitor functional level and reevaluate at each visit Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Stable or diminished distress Increased or persistent distress See Distress Score 4 or moderate to severe distress (DIS-4) � Continue monitoring and support aSee Psychosocial Distress Patient Characteristics (DIS-B). Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Instructions: First please circle the number (0-10) that best describes how much distress you have been experiencing in the past week including today. YES NO YES NOPractical Problems Family Problems Emotional Problems Spiritual/religious concerns Physical Problems � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Child care Housing Insurance/financial Transportation Work/school Dealing with children Dealing with partner Ability to have children Depression Fears Nervousness Sadness Worry Loss of interest in usual activities Appearance Bathing/dressing Breathing Changes in urination Constipation Diarrhea Eating Fatigue Feeling Swollen Fevers Getting around Indigestion Memory/concentration Mouth sores Nausea Nose dry/congested Pain Sexual Skin dry/itchy Sleep Tingling in hands/feet Second, please indicate if any of the following has been a problem for you in the past week including today. Be sure to check YES or NO for each. Other Problems: _________________________________________ ________________________________________________________ SCREENING TOOLS FOR MEASURING DISTRESS Extreme distress No distress 10 9 8 7 6 5 4 3 2 1 0 10 9 8 7 6 5 4 3 2 1 0 DIS-A Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management PERIODS OF INCREASED VULNERABILITY � � � � � � � � � � � � Finding a suspicious symptom During workup Finding out the diagnosis Awaiting treatment Change in treatment modality End of treatment Discharge from hospital following treatment Stresses of survivorship Medical follow-up and surveillance Treatment failure Recurrence/progression Advanced cancer End of life � Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. DIS-B PATIENTS AT INCREASED RISK FOR DISTRESSd � � � � � � � History of psychiatric disorder/substance abuse History of depression/suicide attempt Cognitive impairment Communication barriers Severe comorbid illnesses Social problems Family/caregiver conflicts Inadequate social support Living alone Financial problems Limited access to medical care Young or dependent children Younger age; woman History of abuse (physical, sexual) Other stressors Spiritual/religious concerns e � � � � � � � � � c d For site-specific symptoms with major psychosocial consequences, see Holland, JC, Greenberg, DB, Hughes, MD, et al. Quick Reference for Oncology Clinicians: The Psychiatric and Psychological Dimensions of Cancer Symptom Management. (Based on the NCCN Distress Management Guidelines). IPOS Press, 2006. Available at . From the NCCN Palliative Care Clinical Practice Guidelines in Oncology. Available at . eCommunication barriers include language, literacy, and physical barriers. www.apos-society.org www.nccn.org PSYCHOSOCIAL DISTRESS PATIENT CHARACTERISTICSc Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Distress Management TOC Discussion, ReferencesNCCN ® Distress Management Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Partici