Psycho-Oncology Care: Dr. Erik Bengtsen on Psilocybin & Patient Distress

In oncology nursing, managing psychiatric symptoms and existential distress is a critical component of holistic patient care. Erik Bengtsen, MD, an assistant attending psychiatrist at Memorial Sloan Kettering Cancer Center, serves as psychiatric liaison to the Colorectal Cancer Disease Management Team. Bengtsen works extensively with patients navigating cancer-related anxiety, depression, demoralization, and complex side effects.

In this Q&A with Oncology Nursing News, Bengtsen explores the evolving clinical evidence surrounding psilocybin-assisted therapy for end-of-life anxiety, the crucial supportive role oncology nurses play during investigational protocol sessions, and key strategies for distinguishing demoralization from major depressive disorder.

Additionally, he highlights vital psychopharmacological considerations for patients with altered gastrointestinal anatomy and offers compassionate guidance on reframing conversations about hope, meaning, and unproven alternative therapeutics with patients facing refractory distress.

There is growing interest surrounding psychedelic-assisted therapy in oncology. Where does the clinical evidence currently stand for using psilocybin to treat end of life anxiety and existential distress?

We're very interested in this topic and we're very interested in in digging through this research. If we think to some of the research coming out in 2016, 2017 and building from there at more and more centers and larger patient population studies, patients are obtaining psilocybin at very regulated, very controlled academic medical centers. The data has been emerging that people do well with regards to their anxiety and depression scores.

There's a special focus on this mystical experience. Is there something, a perspective change, where we say there's something bigger than us? Whether that's connection to nature or to the cosmos or to each other or to some other faith-based mystical connection? And is that pathway somehow helpful for patients who feel stuck with day-to-day pain or a limited time left? There's both this perspective change and unique biologic pathway that people have less anxiety or depression 6 months later, 1 year later.

The research has not yet translated to an FDA approval for psilocybin or any of the shorter-acting analogues or metabolites, but there are things that are coming down the pipeline that could be a shorter-duration experience rather than 6 to 8 hours of psilocybin. So we're monitoring the research space. It's still a controlled substance in category 1, so psilocybin is still very difficult to obtain and use from from a research standpoint. That's been one of the limiting factors for this research to grow.

If psilocybin-assisted therapy becomes more widely integrated into psycho-oncology, what will the nurse's role look like during preparation, dosing sessions, and integration?

There are different schools of thought, if this is something that could really help with patients, where should it be done, where should a patient think to take the psilocybin and be supported during that medication effect. There are some people that would say this is best done supervised in an academic medical center. Many of the trials have been two therapists, whether it's a psychologist or social worker in the room with with a patient for the whole experience for support if things like distressing hallucinations come up and how to help somebody feel calmer during that experience, but also talking through different things that come to mind about these existential questions that might come up for each specific patient.

Advanced cancer patients will have more medical co-morbidities and a different level of fragile medical system. So, could there be worsened GI distress and nausea, vomiting, risk of dehydration? These would be some of the arguments to really be in an academic medical center, risk of serotonin syndrome if somebody's on different pain medications like methadone for example for refractory pain and could that interact, there's evolving research, can somebody be on an antidepressant and then use psilocybin, and these things are better monitored at an academic medical center.

Nurses do an amazing job connecting and bringing their humanity to their day to day, we love our nursing staff and they do amazing work and they're brilliant and compassionate and really on the front lines. So, bringing that experience to a patient who has never taken a hallucinogen before, there's going to be some level of uncertainty or fear or anxiety to go into that process. Seeing a familiar face, whether that's a nurse from from the primary oncology team that's been at doctor's visits or at chemotherapy visits or just a warm, medically knowledgeable person being there to connect with the patient before and if any different symptoms come up to help support the patient through that.

I find that different nurses, different doctors have different levels of enthusiasm to learn more about this emerging field. So different nursing staff, different clinicians, different therapists will be more drawn to this to try to help patients through this and and see some improvements.

Beyond novel therapeutics, you work extensively with patients who are experiencing severe demoralization and depression. How do you distinguish demoralization where a patient loses meaning from major depressive disorder in clinical practice?

It can often be a quite difficult to disentangle the both of them. I think our patients often identify more with demoralization. We have plenty of referrals coming from oncologists and surgeons where the patient was so tearful in the room and the oncologist wants them to find some help, to talk to a psychotherapist or a psychiatrist for considering medication management.

Patients often describe it as not a depression. This is something else. This is distress. This is due to the pain. This is due to low energy. This is due to severe fatigue with treatments or with these other medications to deal with the side effects of treatments for example or the cancer itself.

Patients often have good insight themselves. If we do some questioning about what used to matter a lot to you in in your day-to-day, what was your identity, what things brought you joy, things that brought you some sense of connection to others — somebody was a teacher or worked in an accounting firm, whatever it is, can we tap into their prior identity as in their family system as well and their friend structure and their community groups? If people have a really hard time connecting with that sense of themselves and what brings them meaning in life and what's always brought them meaning in the past, we try to work on different things and say, with the demoralization there's also a depression component, could we help your mood and motivation? Could we help your energy to connect with these things that you find meaningful? Some patients, it's very clear they've had depressive episodes in the past before cancer and treatment, and they say this is feeling like a depressive episode from the past and it really responded well to this certain medication, but it's often a mix between the two.

What safety considerations or contraindications should oncology teams keep in mind when evaluating patients who express interest in investigational trials?

It’s very important to always speak with the oncologist and the team or a clinical trial team and the pharmacologist on that team about potential drug-drug interactions. Sometimes the oncologist will say this treatment schedule is very intensive, are we going to be able to find the time to really get into this, or that the treatment is such a high priority, is the quality of life so impacted by depression or existential anguish? And we've tried other first-line agents, such as antidepressants or benzodiazipines or other medications for energy and fatigue, for example, low-dose stimulants. Of course, have we tried more of these first-line agents, exploring with a patient the motivation to try this? What are you hoping to to gain from this? Not to question in a negative way, but just out of curiosity, how could we learn more about you as a person and what do you want to attain from this?

And then consider the the safety of it. The oncologist would also think about things like liver functioning, like can you metabolize these medications? Would we say your liver has been through a lot with treatments or with prior surgeries or causes for cirrhosis or fatty liver and if you pursue this you're going to need a much lower dose than a normal standard dose. There are all these small aspects to really have a thorough discussion with your oncologist.

Managing psychiatric symptoms in patients with complex GI or colorectal cancers involves careful psychopharmacology due to absorption issues and side effects. What medication interactions should oncology nurses keep on their radar?

The most common things I would think about, especially from a psycho-pharmacology perspective, and people have had surgeries or they have a shortened colon, there's a shorter gut, there's a different transit time for any medications that really impacts the usage of extended-release capsules or delayed-release capsules.

We've had patients who stuck with their old antidepressants and then it was quite clear, they said, “I don't think this medication is being absorbed,” and I asked, “How do you know? Is there depression or anxiety coming back?” and they said, “No doc, the capsule's just coming out into my ostomy bag, it's not opened, it's a fully intact capsule,” so we know we have to switch, but it's always a good idea to review this and think about can we move to a shorter-acting tablet.

For example, there's been some development of of dissolvable tablets which will be more absorbed, like sublingual, but especially that the tablet forms into liquid so it could be absorbed more higher in the GI [tract]. … Patients with gastrectomies or whipples, they don't have the same acidic environment, they don't have that pH of the gastric acid to help break down, sometimes patients actually need a higher higher dosage because the the medication is not being broken down and absorbed like before. That's more patient individualized checking in month by month with the symptoms that may be emerging.

How can nurses help reframe conversations about hope and meaning for patients who are struggling with refractory distress and are looking therapeutic options?

We've talked about the alternative psychopharmarmacology options that are emerging. If people are researching things such as, “I read on the internet the high-dose vitamin C or other things to suppress tumors from growing,” and whether that's some some supplement or anti-parasite treatment, we know that patients are feeling desperate. They really want to find some way to beat this or to extend their life or get a better scan and and to be there with family for longer.

So, patients are feeling desperate and then, of course, we read on the internet there's this testimonial, and should I try this? Should I add on this supplement or other alternative therapeutic? I think it's very important for patients to discuss with their nursing team, to discuss with the oncologist, about how would that fit in. And we often are able to consult some databases and say there there's this drug interaction, this is dangerous, this is risky to add this to the picture, or to say this is something that might have a limited research base in the literature that we see, but it's not going to do that much harm, so of course a patient is able to try that if they want to.

For the nursing staff to greet that with the curiosity, the warmth, saying, "OK, we know you're just trying to do everything you can, that's what you've done in other parts of your life, try to research things, try to add on strategies, try to add on different things that might turn the corner here,” so to see that in the patient as a positive thing, they're not trying to necessarily go against medical advice but they're feeling desperate to add on to their treatments.

Transcript has been edited for clarity and conciseness.