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  • 1. Jane Fletcher Psychologist / Director Melbourne Psycho-oncology Service – Cabrini Health Cabrini Monash Psycho-oncology Research Unit Monash University St Vincent’s Hospital Melbourne [email_address] © Jane Fletcher 2009
  • 2. Reactions to breast cancer
    • Vary from person to person
      • Problem  Challenge
      • Life saving  Devastating
    • Process of
      • Adaptation
      • Adjustment
      • Acceptance
  • 3. Reactions to breast cancer
    • Adaptation, adjustment and acceptance
      • In own time
      • In own way
      • Unique experience
        • Depends on persons previous life challenges, coping and personality styles, social support etc
  • 4. Issues after breast cancer
    • Physical issues
    • Social issues
    • Spiritual / existential issues
    • Health care / system issue
    • Emotional and psychological issues
  • 5. Emotional and psychological issues
    • Anger / resentment
    • Uncertainty
    • Loss of control
    • Hopelessness
    • Helplessness
    • Loneliness
    • Anxiety
    • Depression
  • 6.  
  • 7.  
  • 8.  
  • 9.  
  • 10.  
  • 11.  
  • 12. What is depression?
    • A deep persistent sadness and pessimism
    • Can affect anyone at any age
    • Extremely common
      • One in five (20%) people affected by depression at some time in their lives
      • One million Australian adults and 100,000 young people live with depression each year
    • More common in women than men
      • One in four females and one in six males
      • Beyond Blue, 2009
  • 13.  
  • 14.  
  • 15. Edvard Munch, Despair, 1892
  • 16. Edvard Munch, Despair, 1893-4
  • 17. What is anxiety?
    • Feelings of persistent worry and fear
    • Some anxiety is good and motivates us to perform at our best
    • Excessive anxiety result in fight or flight reaction
      • ‘ Fighter’ ready for perceived aggression and unable to relax
      • ‘ Escaper’ (flight response) freezes with anxiety and may avoid upsetting situations or dissociate from the experience
      • Pedersen (2008)
  • 18.  
  • 19. Edvard Munch, Anxiety, 1894
  • 20. Edvard Munch, Scream, 1893
  • 21. Why is identifying and treating depression and anxiety important?
    • Unmanaged depression and anxiety can result in
      • Significant reduction in quality life
      • Increased suicide risk
      • Treatment delays
      • Compliance issues
      • Increased complications
      • Increased health care costs
    • American Psychosocial Oncology Society (2006)
  • 22.  
  • 23. Depression and breast cancer
  • 24. Depression and breast cancer
    • Depression prevalent in 20-50% people with breast cancer
      • At diagnosis – 20%-28%
      • Recurrent disease ~ 50%
      • Advanced disease – 20%-40%
      • Palliative care ~ 27%-77%
    • Depression can be associated with an increased desire for death and increased suicide rate
    • Population rates 5-20% - gender differences
    • (Breitbart et al 2000)
  • 25. Depression and breast cancer
    • Distinguish between ‘upset’ and clinically significant distress
      • Periods of low mood and grief are ‘normal’ reactions to cancer
      • Level of ‘appropriate sadness’
      • Reaction is transient
    • Question depressive disorder when
      • Persistent
      • Impact on individual’s life and functioning
  • 26. Types of depression
    • Major depression
      • Depressed mood > two weeks
      • Also called clinical depression or unipolar depression
      • Range of subtypes
    • Dysthymia
      • Less severe depressed mood that lasts for years
  • 27. Types of depression
    • Mixed depression and anxiety
      • Combination of symptoms of depression and anxiety
    • Bipolar disorder
      • Periods depression and mania
    • Adjustment disorder
  • 28. What causes depression?
    • Biological - monoamine hypothesis
      • Deficiency of the neurotransmitters serotonin, norepinephrine and dopamine in the synaptic cleft between neurons in the brain
    • Psychological factors
      • Significant life events – breast cancer
    • Social
    • Familial predisposition
    • Unknown
  • 29. Relationship between cancer and depression
    • The relationship is complex
    • Depression after breast cancer may be triggered by
      • Diagnosis
      • Other issues related to the breast cancer and its treatment
      • Impact of the cancer person's life
    • May be related to other difficult life events (past or present)
  • 30. Who is most likely to develop depression?
    • Pre morbid depression
    • Socially isolated
    • Other significant life events
    • Co-morbidities
    • Drug interactions and side effects
      • Steroids
      • Opioids
      • Benzodiazepines
  • 31. Who is most likely to develop depression?
    • Pain
      • Significant cause of depression in cancer patients
      • Depression may change perceptions of the meaning and severity of pain
      • Pain or fear of unrelieved pain critical variable in requests of physician assisted suicide
  • 32. Diagnosing depression?
    • DSM – IV TR Criteria: Major Depressive Episode
      • Depressed mood
      • Diminished interest or pleasure in activities
      • Significant weight loss/gain or decrease/increase in appetite
      • Insomnia or hypersomnia
  • 33. Diagnosing depression?
    • DSM – IV TR Criteria: Major Depressive Episode
      • Fatigue or loss of energy
      • Feelings of worthlessness or excessive guilt
      • Diminished ability to think or concentrate or indecisiveness
      • Recurrent thoughts of death or suicidal ideation
  • 34. Criteria for major depression
    • One or both of main emotional symptoms of depression
      • Dysphoria (sadness)
      • Anhedonia (lack of pleasure)
    • Plus at least five of the somatic symptoms
    • DSM-IV TR criteria also require
      • Presence of vegetative and/or somatic symptoms with psychological symptoms and must be present for two weeks and present a significant change from prior functioning
  • 35. Psychological symptoms of depression
    • Dysphoria (sadness)
    • Anhedonia (lack of pleasure)
    • Hopelessness
    • Feelings of guilt
    • Worthlessness
  • 36. Vegetative and somatic symptoms DEPRESSION Alteration in mood (anxiety/depression) Fatigue Low energy Loss of appetite Loss of sleep Psychomotor retardation CANCER AND ITS TREATMENT Pain and other symptoms Fatigue Low energy Loss of appetite Loss of sleep Psychomotor retardation
  • 37. Mnemonic for depression diagnostic criteria
    • SIGECAPS
      • Sleep (increase/decrease)
      • Interest (diminished)
      • Guilt/low self esteem
      • Energy (poor/low)
      • Concentration (poor)
      • Appetite (increased/decreased)
      • Psychomotor (agitation/retardation)
      • Suicidal ideation
  • 38.
    • Major depression
      • Depressed mood for 2 or more weeks plus 4 SIGECAPS
    • Dysthymia
      • Depressed mood, plus three SIGECAPS for 2 years, most days
    • Unipolar - not bipolar disorder with depressed mood
      • If patient who is prescribed antidepressants begin to show manic symptoms may be bipolar
  • 39. Be alert to reports that patients are:
    • Having a very low mood for most of the time
    • Not being able to be lifted out of low mood
    • Not feeling usual self
    • Not being able to enjoy anything
    • Loss of interest in favourite activities
    • Feeling worse in the mornings
    • Problems getting off to sleep or waking early
    • Poor sleeping patterns or sleeplessness
  • 40. Be alert to reports that patients are:
    • Poor concentration and forgetfulness
    • Feelings of guilt/burden/blame
    • Feeling helpless or hopeless
    • Feeling vulnerable or oversensitive
    • Feeling close to tears
    • Irritability
    • Loss of motivation, unable to start or complete jobs
  • 41. Be alert to reports that patients are:
    • Physical hyperactivity or inactivity
    • Loss of interest in sex
    • Thoughts of suicide or death
    • Slow speech; slow movements
    • Drug or alcohol abuse
  • 42. Adjustment disorders
    • Often called minor depression or reactive depression
    • Abnormal and excessive reaction to a life stress
    • Most common mood disorder in cancer patients
    • Symptoms typically begin within 3 months of the stressor, and do not last longer than 6 months after stressor stops
      • Ongoing stressors-breast cancer?
  • 43. Adjustment disorders
    • Diagnostic criteria
      • The symptoms clearly follow stressor
      • The symptoms are more severe than would be expected
      • There do not appear to be other underlying disorders
  • 44. Adjustment disorders
    • Diagnosis requires
      • Sadness or inability to find pleasure in life as a response to stressor like cancer
      • Temporally related to onset of symptoms
      • Symptoms sufficiently severe to cause impairment in social and occupational functioning
  • 45. Treatment for depression
    • If patient depressed refer them to the appropriate health professional/s
      • GP
      • Psychologist
      • Psychiatrist
      • Social worker
      • Counsellor
  • 46. Treatment for depression
    • Pharmacological
      • Antidepressants
    • Psychological
      • Psychotherapy /psychotherapeutic interventions
    • Lifestyle factors
      • Exercise
      • Sleep
  • 47. Pharmacological – antidepressants
    • Prescribed medical doctor
    • Best when combined with psychological / psychotherapeutic interventions
    • Use for major depression or when symptoms are severe - patient dependent
    • Mechanisms differ depending of class
      • Norepinephrine
      • Serotonin
  • 48. Pharmacological – antidepressants
    • Between 2-4 weeks to take effect
    • Monitor side effects and symptom response
  • 49. Pharmacological – antidepressants
    • Side effects are usually mild and resolve within first few weeks
      • Dry mouth
      • Drowsiness
      • Nausea
      • Sleeplessness
      • Sexual problems
      • Headaches
  • 50. Pharmacological – antidepressants
    • Classes commonly used in cancer patients
    • Tricyclic antidepressants (TCAs)
      • More side-effects than newer drugs
    • Monoamine oxidase inhibitors (MAOIs)
      • Difficult to use due to drug-drug and drug-food interactions
  • 51. Pharmacological – antidepressants
    • Classes commonly used in cancer patients
    • Selective serotonin reuptake inhibitors (SSRIs) eg Sertraline – Zoloft, Fluoxetine – Prozac/Lovan
      • Highly effective
      • Reduced side effect profile
      • Generally non sedating
  • 52. Pharmacological – antidepressants
    • Classes commonly used in cancer patients
    • Serotonin and noradrenaline reuptake inhibitors (SNRIs) eg Venlafaxine – Effexor
      • Fewer side effects
      • Effective in severe depression
      • May assist with hot flushes and neuropathic pain
  • 53. Pharmacological – antidepressants
    • Classes commonly used in cancer patients
    • Noradrenaline-serotonin specific antidepressants (NaSSAs) eg Mirtazapine– Remeron
      • Relatively new antidepressants 
      • Particularly helpful when there are problems with anxiety or sleep
      • Generally low in sexual side-effects
  • 54. Psychological interventions
    • Provided by
      • Psychologist
      • Psychiatrist
      • Social Worker
      • Counsellors / Psychotherapist
      • Some GPs
    • Check qualifications and experience in dealing with cancer patients
  • 55. Psychological interventions
    • Types of therapies include
      • Cognitive Behavioural Therapy (CBT)
      • Supportive or existential psychotherapy
      • Acceptance and Commitment Therapy (ACT)
    • Therapy is usually individualised and will differ for each person
    • Many therapists will use a range of techniques
  • 56. Psychological interventions
    • Cognitive Behavioural Therapy
      • Present based
      • Teaches problem solving
      • Reframing attitudes
      • Challenges ‘black and white thinking’
      • Relaxation skills
      • Guided imagery
  • 57. Psychological interventions
      • Supportive or existential psychotherapy
        • Encourages expression of emotion
        • Validates individual experience
        • Support through empathic listening and encouragement
        • Utilises information provision
        • Highlights strengths of individual
        • Encourages use of adaptive coping
  • 58. Psychological interventions
    • Acceptance and Commitment Therapy
      • Acceptance of what is out of your personal control, while committing to do whatever is in your personal control
      • Teaches psychological skills to deal with painful thoughts and feelings effectively – mindfulness skills
      • Helps to clarify what is truly important and meaningful i.e. values - then use that knowledge to guide, inspire and motivate person to change life for the better
  • 59. Lifestyle factors
    • Exercise
      • Evidence exercise improves mood
    • Diet
    • Sleep
      • Getting enough sleep
      • Good sleep hygiene
    • Natural therapies
      • St John’s Wort
  • 60. Anxiety and breast cancer
  • 61. Anxiety and breast cancer
    • Anxiety ~ 35% of patients with cancer diagnosis
      • Range of disorders with different rates
    • (Zabora et al, 2000)
  • 62. Anxiety and breast cancer?
    • Feelings of anxiety increase or decrease at different times
    • Most patients are able to reduce their anxiety by learning more about their cancer
    • For some, particularly those who have experienced episodes of intense anxiety before their cancer diagnosis, feelings of anxiety may become overwhelming
    • Most patients who have not had an anxiety condition before their cancer diagnosis will not develop an anxiety disorder associated with cancer
  • 63. Anxiety and breast cancer
    • Some level of anxiety is a normal reaction to breast cancer
    • Difficult to distinguish between normal fears associated with cancer and abnormally severe fears that can be classified as an anxiety disorder
    • Anxiety associated with cancer may increase
      • Feelings of pain
      • Interfere with sleep
      • Nausea and vomiting
      • Reduce quality of life
  • 64. What is anxiety?
    • Primary psychiatric disorders
    • Generalized anxiety disorder (GAD)
      • Pervasive feeling of dread or apprehension
    • Panic disorder +/- agoraphobia (avoidance of places that may result in panic)
    • Obsessive-compulsive disorder
    • Post traumatic stress disorder
  • 65. What is anxiety?
    • Cancer related anxiety
    • Psychological anxiety can be interpreted as a reaction to a threat
    • Anxiety increases in certain situations
      • Initial diagnosis
      • Treatment
      • Lead up to follow up appointments
      • Waiting for test results
      • Recurrence
  • 66. What is anxiety?
    • Phobic reactions
    • Anxiety that may lead to full blown panic
      • Claustrophobic patients and MRI/CT scans
      • Needle phobia
      • White coat syndrome
  • 67. What is anxiety?
    • Conditioned response
    • Anticipatory nausea
      • Often associated with anxiety
    • PTSD
      • Survivors
      • Undergo additional treatment
  • 68. Anxiety related to breast cancer
    • Some persons may have already experienced intense anxiety in their life because of situations unrelated to their cancer
    • These anxiety conditions may recur or become aggravated by the stress of a cancer diagnosis
    • Patients may experience extreme fear, be unable to absorb information given to them by health professionals, or be unable to follow through with treatment
  • 69. Signs and symptoms of anxiety
    • Psychological
      • Worry, apprehension, fear and sadness
      • Patients may be able identify focus or source of these symptoms
      • Often non-specific and ‘free floating’
      • Crying spells, ruminations
      • Inability to ‘turn off’ – especially at night
  • 70. Signs and symptoms of anxiety
    • Physical
      • Tachycardia and tachypnea
      • Tremor
      • Diaphoresis
      • Nausea
      • Dry mouth
      • Insomnia
      • Anorexia
  • 71. Signs and symptoms of anxiety
    • May be intermittent – increasing over hours or days
      • Occurs in response to stressor - anticipation of upcoming diagnostic test and passes once stressor over
    • May be persistent and pervasive through day
      • Typical of primary anxiety disorders
      • Co-morbid depressive symptoms
      • Reactions to chronic stressors (eg fear of recurrence, family and financial problems)
      • Side effects of regular medication
  • 72. Signs and symptoms of anxiety
    • Panic attacks present with acute anxiety
      • Severe palpitations, perspiration and nausea
      • Great fear of catastrophic event
        • Feeling of impending doom
      • Usually last for several minutes
        • Multiple events can occur in one day
  • 73. Be alert to reports that patients are:
    • Feeling shaky, jittery, or nervous
    • Tense, fearful, or apprehensive
    • Having to avoid certain places or activities because of fear
    • Palpitations
    • Trouble catching breath when nervous
    • Unjustified sweating or trembling
    • Knot in stomach
    • Lump in throat
  • 74. Be alert to reports that patients are:
    • Pacing
    • Afraid to close eyes at night for fear that may die in sleep
    • Worry about the next diagnostic test, or the results of it, weeks in advance
    • Sudden fear of losing control or going crazy
    • Sudden fear of dying
    • Intense worry about pain or other physical issues
    • Confusion or disorientation
  • 75. Who is most likely to develop anxiety disorder?
    • History of anxiety disorders
    • Experiencing anxiety at the time of diagnosis
    • Severe pain
    • Socially isolated
    • Non responsive cancer
    • History of severe physical or emotional trauma
    • Cancer medications and treatments
  • 76. Treatment for anxiety disorders
    • If patient anxious refer them to the appropriate health professional/s
      • GP
      • Psychologist
      • Psychiatrist
      • Social worker
      • Counsellor
  • 77. Types of treatment for anxiety disorder
    • Depends on how the anxiety is affecting daily life
    • Treat the cause of anxiety if possible
      • Pain or another medical condition
      • Medication side effect
    • All treatment begins with adequate information and support
    • Medications may be used alone or in combination with psychological therapies or strategies
  • 78. Treatment for anxiety disorder
    • Pharmacological
      • Anti-anxiety
      • Antidepressants
    • Psychological
      • Psychotherapy /psychotherapeutic interventions
    • Lifestyle factors
      • Exercise
      • Sleep
  • 79. Pharmacological therapies
    • Anti-anxiety medication
    • Benzodiazepine
      • Short acting such as lorazepam (Ativan) and alprazolam (Xanax)
        • Rapid action
        • Useful for intermittent acute anxiety or panic
        • Pre meds
        • Preferred in seriously ill
  • 80. Pharmacological therapies
    • Anti-anxiety medication
    • Benzodiazepine
      • Longer acting such as diazepam (Valium) and clonazepam (Klonopin)
        • Useful for more persistent anxiety
        • Less tolerance
      • Fear of addiction vs. symptom control
  • 81. Pharmacological therapies
    • Anti-anxiety medication
    • Antipsychotic drugs
      • Haloperidol (Haldol)
        • Use in low doses for anxiety
        • Especially if agitation and tremor present
  • 82. Pharmacological therapies
    • Anti-anxiety medication
    • Opioid analgesics
      • Morphine
        • Effective in terminally ill
  • 83. Pharmacological therapies
    • Anti-anxiety medication
    • Antidepressants
      • Patients with pre existing anxiety
      • No used on an ‘as needed’ basis
      • SSRIs
  • 84. Psychological interventions
    • Types of psychological therapies include
      • Psycho-education
      • Active problem solving
      • Cognitive Behavioural Therapy (CBT)
      • Supportive or existential psychotherapy
      • Acceptance and Commitment Therapy (ACT)
      • Mindfulness Based Stress Reduction (MBSR) techniques
  • 85. What else is helpful?
  • 86. Helpful psychological strategies
    • Expressive therapies
      • Journaling
      • Music
      • Art
    • Self-help groups
    • Peer support
  • 87. Helpful psychological strategies
    • Stress reduction techniques
      • Mindfulness based stress reduction - meditation
      • Relaxation techniques
      • Guided imagery
      • Biofeedback
    • Hypnosis
  • 88.  
  • 89.  
  • 90. Helpful psychological strategies
    • Mindfulness exercise
      • Yoga
      • Tai Chi
      • Qigong
  • 91. Relaxation techniques
    • 1 – 10
    • Deep breaths
    • Relax, relax, relax………………
    • Metronome / clock
    • Progressive muscle relaxation
    • Mindful focus on the breath
    • Special place
  • 92.  
  • 93.  
  • 94.  
  • 95.  
  • 96.  
  • 97.  
  • 98. Screening for distress
    • Goal
      • Early detection
      • Early assessment / referral
      • Early treatment / intervention
    • Early detection = screening on a routine basis
    • Embedded in routine care at multiple time intervals
  • 99. Screening for distress
    • Distress Thermometer
      • 0–10 visual analogue scale - indicate level of distress on the scale
      • "No Distress" at 0
      • "Moderate Distress" at the midpoint
      • "Extreme Distress" at 10
      • Supplementary questions covering various areas of distress (e.g. family problems, physical problems)
  • 100.  
  • 101. Screening for distress
    • Distress Thermometer
      • Cut off for referral generally 4
      • Referral to appropriate source given results of problem list
      • Re screen on a regular basis
        • Evaluate outcome of intervention and referral
  • 102. Other measures to screen for distress
    • K10
      • 10 items measuring anxiety and depression symptoms
      • Used by GPs as part of MHCP assessment
      • Scores 20 or above indicative of disorder and need referral for assessment and treatment
  • 103.  
  • 104.  
  • 105. Simple questions to assess mood
    • Three questions used in primary care to detect depression
      • During the past month, have you been bothered by feeling down, depressed, or hopeless?
      • During the past month, have you been bothered by little interest or pleasure in doing things?
      • Is this something with which you would like help?
      • Arroll et al 2005
  • 106. Simple questions to assess mood
    • Other questions that may be useful
      • ‘ Anxiety is understandably common in people who have been treated for cancer. Would you say that anxiety is an issue for you?’
      • ‘ Coping with cancer isn’t just about physical issues, the emotional impact is important too.’ ‘Could you tell me what the cancer has meant emotionally?’ ‘Would say that you have ever felt really sad or depressed?’
      • NBOCC & NCCI, 2003
  • 107. Cancer Helpline 13 11 20 Speak to GP or health professional Medicare rebateable psychological assistance under the Better Outcomes in Mental Health Care program is available – discuss with GP Those who need help are not alone
  • 108.