Depression in Oncology and Palliative Care

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Depression in Oncology and Palliative Care

• Chris Hosker

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ME

• Special interest in palliative care psychiatry
  psycho-oncology
• hospice based palliative care clinic
• A psycho-oncology clinic at the Leeds Oncology
  Institute

• Consultant Liaison Psychiatrist
• -in reach service for in patients
• -A general liaison psychiatry clinic

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NICE SPC 2004
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Emotional disorders and outcome

• Quality of life
• Outcome Breast Cancer Falagas 2007
• Length of stay
• Treatment adherence
• More frequent admissions

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Epidemiology
Half of all oncology patients have a clinical
psychiatric disorder at any one time (Cull 1990)

• Affective disorders
• Women following breast surgery 25 affective
  disorder (Fallowfield 1990)
• Two year study of 600 patients 20 affective
  disorder (Parle 1996)
• Regional cancer attendees 8 had MDD (Sharpe
  2004a)
• (Most were on no effective therapy for this)

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Depression near EOL

• Depressed mood and sadness common
• Nature of disease
• Effects of treatment
• Major depression not common
• Spectrum
• Adj disorders in up to 51

Normal adjustment
Adjustment disorder
Psych disorder
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Validity of psychiatric methods
DSMIV ADJUSTMENT DISORDER
Development of emotional or behavioural symptoms
in response to an identifiable stressor
Within 3 months of the onset of the stressor
Marked distress in excess of that expected from
stressor
Significant impairment in social or occupational
functioning
Disturbance does not meet criteria for any other
disorder
Does not persist for longer than 6 months
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Distressed Patients
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Obstacles to diagnosisSevere depression is
under-diagnosed and undertreated

• Reasons
• Lack of time
• Difficulty recognising symptoms (Fallowfield
  2001)
• Normal, inevitable, appropriate response
• Patients will not respond to treatment
• Stigma of referral
• Adverse effects from medication
• Collusion due to fear of exacerbating distress

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How do oncologists diagnose depression?

• Lawrie 2004
• Palliative medicine
• 73 routinely screened
• 50 used a formal method
• 10 used one question are you depressed?
• 27 used HADS
• Mitchell 2008
• Oncology
• 63 routinely asked about mood
• 37 only occasionally asked

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Increasing chance of succesfull diagnosis

• Proportion of the interview used for emotional
  enquiries
• Use of open ended questions
• (Badger et al 1994)

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Validity of psychiatric methods

• ICD 10 Depression
• Low mood
• Loss of energy
• Anhedonia
• (at least 2)
• Loss of self Confidence
• Guilt
• Suicidal thoughts
• Poor Concentration
• Psychomotor retardation
• Poor sleep
• Loss of Weight

• Loss of Reactivity
• Diurnal variation
• (at least 2)
• Occurring on most days for 2 weeks

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Diagnostic approaches
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Endicott substitution criteria
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Endicott substitution criteria
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Cognitive questions
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Risk factors for depression in palliative care
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How can we diagnose distress?
Physical Problems ? General appearance ?
Fatigue / tiredness Pain - general Pain - wound ?
Skin - dry / itchy / discoloured ? Broken skin
/ Pressure sores ? Circulatory problems ?
Forgetfulness / memory ? Appetite / eating ?
Weight loss or gain ? Breathing /
breathlessness ? Bowels - constipation /
diarrhoea ? Mobility - getting around ? Mouth
sores / denture problems ? Nausea / sickness /
indigestion ? Sleep ? Lymphoedema / swelling of
limbs Spiritual/religious concerns ? Loss of
religious faith ? Difficulty relating to God ?
Loss of meaning or purpose of life

• Practical Problems
• ? Housing
• ? Insurance/Finance
• ? Work/School
• ? Transport
• Child Care
• Family/Social Problems
• ? Relationship with partner
• ? Relationship with children
• ? Coping with elderly relatives and/or dependents
• ? Loss of social life
• Emotional Problems
• ? Worry
• ? Sadness
• ? Depression
• ? Nervousness/anxiety
• ? Anger
• ? Loss of enjoyment

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gt Symptoms
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Common Tools for Detection of Emotional Disorders
in Cancer Settings Distress Profile of Mood
States (POMS) Psychosocial Adjustment to Illness
Scale (PAIS) Brief Symptom Inventory
(BSI) Symptom Checklist 90-R (SCL-90) Distress
Thermometer Anxiety State-Trait Anxiety
Inventory Hospital Anxiety and Depression Scale
Anxiety subscale Impact of Events Scale
(IES) Fear of Progression Scale
(FoP12) Depression Beck Depression Inventory
(BDI-II) Montgomery-Åsberg Depression Rating
Scale (MADRS) Zung Self-rating Depression Scale
(SDS) Centre for Epidemiologic Studies Depression
Scale (CES-D). Hospital Anxiety Depression Scale
(HADs), the Geriatric Depression Scale (GDS), he
Edinburgh Postnatal Depression Scale
(EPDS) Patient Health Questionnaire (PHQ9).
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Diagnosis

• Clinical interview is the gold standard
• Self report measures useful precursor

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Management of depression

• Its all about relationships
• Support
• Acknowledging distress
• Whole person
• Ongoing contact

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Practical recommendations A. Time 1. Spend a
reasonable amount of time with the distressed
patient 2. See distressed patients on more than
one occasion 3. Be prepared to make a diagnosis
after several appointments rather than
instantaneously B. Confidence 4. Recognize that
many people present with physical symptoms 5. Ask
all new patients (who do not have insignificant
reasons for consultation) about wellbeing 6. Ask
all patients who are distressed (and those at
high risk of depression) about i. low mood ii.
Loss of interest iii. Reduced motivation /
participation C. Clinical Suspicion 7. Be alert
to distress in all patients with significant
comorbidity 8. Be alert to distress / depression
in those with current psycho-social concerns, low
social support and recent adverse life events (eg
bereavement). 9. Ask all patients with
psychosocial concerns and particularly those in
distress, if they want professional help at the
current time.
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Psychosocial interventions
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Pharmacological treatment

• Can provide quick symptom reduction
• 2-4 weeks action
• Psychostimulants?
• Efficacy in cancer established (Costa 1985)
• 1046 terminally ill patients
• 10 prescribed antidepressant
• 76 started within two weeks of death
• (Lloyd-Williams 1999)

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Antidepressants

• Start low, go slow

• SSRIS
• Fluoxetine
• Citalopram
• Sertraline
• (Avoid if using procarbazine)
• Trazadone
• Mirtazapine
• TCAs
• MAOIs

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Suicide

• An enquiry into suicidal ideation should be made
  in any one who is suspected of being depressed
• Increased risk
• Malignant neoplasms
• Head and neck cancers
• Risk highest immediately following diagnosis
• 40 of suicides within the first year

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Most patients with cancer have passing thoughts
about suicide