Chronology of distress, anxiety, and depression in older cancer aa 2 5 13


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Evidence-based, but practical..and comes out against routine screening for distress unless system in place to offer treatment

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Chronology of distress, anxiety, and depression in older cancer aa 2 5 13

  1. 1. Chronology of Distress, Anxiety, and Depression in Older Cancer Patients International Workshop on PalliativeCare to the Geriatric Oncology Patient Muscat, Sultanate of Oman, February 10-13, 2013 James C. Coyne, Ph.D. Department of Psychiatry, University of Pennsylvania Health Psychology Program, University of Groningen
  2. 2. Do older cancer patients experience fewerpsychological symptoms- anxiety anddepression?Previously answered “of course,” but becomingcontroversial idea.
  3. 3. Major depression 15% Anxiety disorders 10%Dysthymia 3%
  4. 4. • Cancer is less disruptive of social roles such as parenting and employment• Greater acceptance of mortality, inevitability of end-of-life• Diagnosis and experience of cancer interpreted in the context of larger physical co-morbidities
  5. 5. Different themes for oldercancer patients:•Patients’ perception of effectson family members: familyburden•Lost opportunity to witnessfamily transitions•Widowhood and socialisolation (important predictorsof non-remission of clinicaldepression)
  6. 6. In general, major depression in the context of ageneral medical condition has longer episodesand a greater likelihood of relapse andrecurrence.In the case of cancer, attention to depression isoften sacrificed to the competing priority ofdealing with the cancer, despite the reduction inmorbidity that would be achieved by effectivetreatment of depression.
  7. 7. Depression among cancer patients isassociated with:•Negative impact on patient’s quality of life•Reduced acceptance of and compliance withtreatment plans•Prolonged hospitalizations•Reduced effective coping•Desire for early death or suicide
  8. 8. Trajectory of adaptation to a diagnosis of cancer and its treatment
  9. 9. Normal response to diagnosisof cancer is upset, sadness,fright, and worry about thefuture.It is difficult to immediatelyestablish whether response isabnormal and when formalpsychiatric diagnosis andtreatment are appropriate.
  10. 10. Much of initial response to cancer diagnosis isself-limiting or responsive to attention andsupport and better information.By six months, residual distress tends to haveexisted before diagnosis, be tied to non-cancerfactors, or reflect neuroticism or psychiatriccomorbidity.
  11. 11. Different Patterns of Adjustment656055 Cut Point50 Never Disressed45 Resolved Distress Chronic Distress403530 Diagnosis 3 Months 6 MonthsNever Distressed  52% of sample; No Elevations over timeResolved Distress  36% of sample; Elevated distress at diagnosis that resolves by 3 monthsChronic Distress  12% of sample; Elevated distress at all times
  12. 12. Deferred diagnosis of mild mental disorder, supportive action (stepped diagnosis, stepped care)
  13. 13. On the other hand, be alert to the earlyemergence of psychiatric disorder,particularly among patients with a pasthistory•Vegetative symptoms such as psychomotorretardation, extreme insomnia•Pathological guilt and excessive self-blame
  14. 14. It is controversial whether cancer is associatedwith psychiatric co-morbidity more than with otherphysical health conditions.The challenge is making a diagnosis andensuring adequate follow up within the competingdemands of dealing with a life-threateningcondition.
  15. 15. In general, major depression in the contextof a general medical condition has longerepisodes and a greater likelihood of relapseand recurrence. In the case of cancer, attention to depression is often sacrificed to the competing priority of dealing with the cancer, despite the reduction in morbidity that would be achieved by effective treatment of depression.
  16. 16. • 25 studies• Antidepressants more efficacious than placebo at 4-5, 6-8, and 9-18• Superiority over placebo is apparent within 4-5 weeks and increases with continued use.
  17. 17. Detecting psychiatric morbidity: The argument against routine screening of cancer patients for depression and anxiety
  18. 18. Effective care for depression requires accuratediagnosis and follow up.Routine care for depression in general medicalsettings typically no better than receivingplacebo in a clinical trial.Estimated that 40% of general medical patientsreceiving treatment for depression achieve nobenefit over remaining on waiting list.
  19. 19. Rather than routinely screeningpatients for depression and placingthem in inadequate routine carewithout follow-up:•Concentrate on ensuring better follow-upcare for known cases of depression•Concentrate on patients at high risk for depression
  20. 20. Be aware of the limitations of common self-report screening instruments:•Cut points may not hold in another languageand culture unless cross validated•Do not reliably distinguish between anxiety anddepression symptoms•Do not translate well (ex.- butterflies in thestomach)
  21. 21. The Hospital Anxiety andDepression Scale (HADS)should not be usedCoyne JC, van Sonderen E:The Hospital Anxiety andDepression Scale (HADS) isdead, but like Elvis, there willstill be citings. Journal ofPsychosomatic Research.73:77-78.
  22. 22. Importance of history psychiatric disorder
  23. 23. Psychiatric disorders tend to be recurrent andepisodic, with onset the late teens or early 20s.Most psychiatric disorders in cancer patients willbe recurrences, so past history a good predictor.Late onset depression is treatable, but lessresponsive than a recurrence.
  24. 24. • Anhedonia• Apathy• Pain, fatigue masquerading as depressive symptoms
  25. 25. Many depressed patientsdo not renew prescriptions.About half require dosageadjustment, medicationchanges, or educationabout adherence at fiveweeks to achieve benefits.
  26. 26. Dont neglect needs of informal caregivers.Initial symptomatology of women is higher thanmen, regardless of whether they are patients orspouses.
  27. 27. A key issue in the management of depressionamong elderly cancer patients is not theavailability of efficacious treatments, butensuring their effective delivery and follow-up.
  28. 28. Collaborative care for depression:• At least 79 evaluations, 4 with the elderly, 3 with cancer patients• Interdisciplinary team approach• Key element is a depression care manager, usually a nurse• Effect sizes in the range of => .30-.40
  29. 29. Is there an app for this?Challenge of collaborative care issustainability, cost of caremanagerApp decision aids for providersCell phone support, remindersfor patients
  30. 30. Thank you!jcoynester@gmail.comFollow me on Twitter@CoyneoftheRealm