Institute Study Day: 2 May Leslie G Walker Professor of Cancer Rehabilitation

Transcription

1 Institute Study Day: 2 May 2007 Leslie G Walker Professor of Cancer Rehabilitation

2 Nature of Morbidity Diagnosis Surgery Chemotherapy Radiotherapy Hormone therapy Disease itself Anxiety Depression Sexual problems Body image Nausea and vomiting Fatigue Pain Functional limitations Damocles syndrome

3 Damocles Syndrome Richard Westall, 1812

4 Damocles Syndrome Preoccupied with, and distressed by, the future Tyrannised by the next test or assessment Stop planning because of uncertainty Unreasonably pessimistic about the future - cannot enjoy his/her self just in case ( tempting fate ). Unable to stand down the guard

5 Mental Health of Patients 1970s 47% of patients with cancer have a psychiatric disorder (Derogatis et al, 1983) 25%-33% of women with breast cancer have clinically significant depression, anxiety and/or sexual problems (Maguire et al, 1980) 81% of women with breast cancer had a psychiatric disorder during combination chemotherapy (Maguire, 1980)

6 Mental Health of Patients 1990s Of 269 women with early breast cancer, 49.6% were clinically anxious and 37.2% were clinically depressed in the first 3 months (PSE) (Hall et al, 1999). 36% of 2,297 patients with cancer at OP clinics in 34 cancer centres in the UK were GHQ-12 positive (oncologists misclassified 35%) (Fallowfield et al, 2001) 33% of patients with newly diagnosed inoperable lung cancer had clinically significant depression, which in many cases was persistent (Hopwood and Stephens, 2000).

7 Why? How? When? Screening

8 WHO Screening Criteria The condition screened for should be an important one There should be an acceptable treatment for patients with the disease The facilities for diagnosis and treatment should be available There should be a recognised latent or early symptomatic stage There should be a suitable test or examination which has few false positives - specifity - and few false negatives sensitivity The test or examination should be acceptable to the population The cost, including diagnosis and subsequent treatment, should be economically balanced in relation to expenditure on medical care as a whole

9 Screening - How Written questionnaires Computerised questionnaires Screening questions Screening interview

10 Screening - Conclusion Instead of a desk. a questionnaire! Problems of sensitivity and specificity Use screening questions followed by assessment if indicated What to do with a positive result?

11 Assessment Nature of the problem(s)/syndrome Predisposing factors Precipitating factors Perpetuating factor

12 Triple Criteria Severity Persistence Interference

13 Overview Depression Anxiety Adjustment disorders Phobias Delirium

14 Depression An unpleasant emotion Associated with the perception of loss A normal feeling A syndrome

15 Epidemiology Incidence (10-25% in women; 5-12% in men) Prevalence (5-9% women; 2-3% men) (?25% in diabetes, MI, stroke, Ca) Seasonality Under-diagnosed Natural history 8 months (RCP)

16 Early Breast Cancer in Hull DSM IV HADS - A HADS - D BL - 6 weeks post surgery EP1-18 weeks post surgery EP2-24 weeks post surgery 10% 5% 7% 14% 7% 10% 4% 1% 1%

17 Associated Aspects 5-15% of people with severe depression die from suicide May affect response to CT Independent prognostic factor for survival in lymphoma Depression increases mortality by x4 in over 55s Increased pain, other illnesses and poorer functioning Depressed men often drink excessively or use drugs

18 Factors involved in depression Biological Genetic (x1.5-3 with first degree relative, 25-75% if bipolar; MZ twins 76%, DZ 67%) Biochemical (Cort, PL, GH) and brain function (HTh) Hormonal (Post partum) Immunological Other biological (Medical conditions and Rx induced) Altered brain chemistry (esp. serotonin and nor adrenaline) Environmental (loss) Early (abuse) Current Future (Damocles ) Social (Brown life) Personality (anankastic, hysterical, dependent, cyclothymic) Psychological learned helplessness, aboulia, cognitive distortions, self-esteem

19 HADS D 6 Study One (CVAP) 6 Study Two CVAP - Docetaxel Mean (SE) 4 2 Mean (SE) Chemotherapy S RT FU4 FU12 Chemotherapy S RT FU4 FU12

20 Assessment 1. Full psychological and social history 2. MSE 3. Predisposing factors 4. Precipitating factors 5. Perpetuating factors

21 Diagnosis Screening DSM IV/ICD10 criteria Triple criteria (SIP) Psychotic dimension Bipolar dimension Atypical Substance Abuse Grief

22 Depression: Emotional Depressed mood (most days, most of the time) Diurnal variation Lack of reactivity Loss of interest Anhedonia Lack of energy Fatiguability Anxiety Irritability

23 Depression: Cognitive Suicidal ideation Depressive cognitions (past, present, future) Low self confidence Low self esteem Excessive guilt Memory Concentration Indecisiveness Hypochondriasis Delusions Hallucinations

24 Depression: Behavioural Sleep disturbance (early morning wakening) Appetite change Weight loss Change in libido Agitation Retardation Amennorhea Constipation Tearfulness Social withdrawal Decreased talkativeness Suicidal behaviour

25 DSM IV Criteria: Major Depression Time frame is a consecutive period of 2 weeks. Five of the following present of which one or more should be: 1. depressed mood most of the day nearly every day and /or 2. loss of interest or pleasure in almost all activities most of the day nearly every day And the remaining (to make five) from: 3. significant weight loss or gain or an increase or decrease in appetite nearly every day 4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly every day (observable by others) 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or inappropriate guilt nearly every day (not merely self reproach about being sick) 8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or observation of others) 9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation (with or without a plan). And the symptoms cause clinically significant distress or impairment in occupational or other important areas of functioning

26 Depression in Patients with Cancer Endicott Substitution Criteria Conventional Symptoms Substituted Symptoms appetite/weight sleep fatigue/energy concentration/indecisiveness tearful/looks depressed withdrawal/reduced talkativeness brooding/self pity/pessimism lack of reactivity

27 Depression as a Sx Epilepsy Diabetes Hypothyroidism Hyperthyroidism Hypoparathyroidism Hyperparathyroidism Multiple sclerosis Stroke Brain trauma Porphyria Wilson's disease (Cu) Lyme disease (ticks) Syphilis Pellagra (niacin deficiency) Huntington's disease Parkinson's disease Paraneoplastic syndrome Cancer of the pancreas Drug intoxication Drug withdrawl

28 Psychiatric DDx Dysthymia Adjustment disorder Grief Demoralisation Anxiety Acute confusional state Schizophrenia CFS

29 Biological Treatments 1. ECT (psychotic depression, retardation, severe suicide risk) 2. Antidepressants (moderate and severe depression) Side effects, interactions, switching, augmentation) 3. Lithium Tricyclics (amitriptyline, clomipramine, imipramine) SSRIs (sertraline, citalopram, fluoxetine, paroxetine) SNRIs (venlafaxine, reboxetine) NASSAs (mirtazapine) MAOI (moclobemaide)

30 Psychotherapeutic Treatments For mild - moderate depression: Cognitive Behaviour Therapy (APT) Interpersonal Psychotherapy Problem Solving Therapy Supportive Psychotherapy Psychodynamic psychotherapy Marital/family therapy Grief therapy For moderate-severe depression Combined psychopharmacology and psychotherapy.

31 Other Interventions Exercise therapy Bibliotherapy

32 Effectiveness About 30% placebo response Antidepressants and psychotherapy have similar response rates (50-65%) in moderate depression. In cancer, may be different. Antidepressants may work faster. Need for dose adjustment

33 Suicide Facts and Figures Distinguish suicide (S) and deliberate self harm (DSH) Up to 15% of clinically depressed die from S 8 th leading cause of death in USA Incidence increasing in young people ( 7 males to 1 female) S four times more common in males than in women DSH twice as common in women Ratio of DSH to S is 8-25:1 In UK most common methods are hanging (males) and overdose (females). In USA, most commonly firearms. For further information see

34 Suicide Risk Factors Psychiatric disorder (esp. depression, schizophrenia) Drug abuse Alcohol intoxication Getting affairs in order Preparing a suicide note Recent discharge from psychiatric hospital Adverse life events (money) Occupation such as farmer, doctor, dentist, vet. Unemployed Divorced FH of psychiatric illness FH of suicide Previous attempt Incarceration Modelling (family, media, films) For further information see

35 Conclusions Depression is common, and under treated, in people with cancer It is potentially lethal Aetiology is often complex and multifactorial Depression can often be prevented Effective treatments are available

36 Anxiety Disorders adjustment disorder post-traumatic stress disorder phobias panic disorder/agoraphobia generalised anxiety disorder

37 Adjustment Disorders Imprecise diagnosis Response to identifiable psychosocial stressor Excessive distress and/or interference with social/ occupational function Behavioural/emotional symptoms (anxiety/depression)

38 Management: General Measures Remove stressor if appropriate Provide information about symptoms Reassure realistically Teach coping skills Provide support

39 Management Relaxation Therapy Anxiety Management Training Cognitive Behaviour Therapy Supportive Psychotherapy Antidepressants for panic attacks Avoid benzodiazepines (except for emergency and as an hypnotic)

40 Post-Traumatic Stress Disorder Disorder Exceptionally threatening/catastrophic event (e.g. life threatening illness) Persistent re-experiencing (intrusive thoughts, flashbacks, dreams, cues) Persistent avoidance of cues and numbing Increased arousal Significant distress/impairment

41 Management Anxiety Management Training Cognitive Behaviour Therapy Supportive Psychotherapy Eye Movement Desensitisation and Reprocessing (EMDR) Antidepressants (SSRI)

42 Phobias Blood-illness-injury, needles and procedures. Anxiety Management Training, Hypnotherapy. In emergency, a benzodiazepine.

43 Delirium: definition Delirium from L. delilare to be crazy; de leave lira furrow. a transient, essentially reversible dysfunction in cerebral metabolism that has an acute and sub-acute onset and is manifest clinically by a wide array of neuropsychiatric abnormalities. (Wise and Brandt, 1992)

44 Delirium: overview Disturbance of arousal (concentration, attention, clouding of consciousness) Change in cognition (memory, orientation, language, perception, perplexity) Not attributable to dementia or depression Rapid onset, fluctuating course Demonstrable or presumed medical aetiology

45 Epidemiology 15-30% cancer inpatients 40-85% patients with cancer in hospice cf.?25% post surgical terminal confusion (63%)

46 Subtypes and Distress Hyperactive (hallucinations, delusions, hyperarousal) ~ withdrawal syndromes (delirium tremens) Hypoactive (sleepy, withdrawn, slowed) ~ encephalopathies, BZP intoxication 50% of patients remember being delirious 90% of those patients who remember found it distressing Partners even more distressed Nurses also distressed (esp. if severe, reversed sleep-wake cycle, hallucinations, delusions, sepsis, dehydration).

47 Reversibility On average 3 aetiological factors Irreversible - hypoxic encephalitis and metabolic causes Reversible psychoactive medication and dehydration

48 Symptoms Confusion Disorientation Impaired STM Impaired attention Disorganised speech Hallucinations Delusions Restlessness Sleep wake cycle Anxiety Emotional lability Somnolence/withdrawal Agitation Aggression

49 Assessment DSM IV ICD 10 Diagnostic interviews Rating scales (MDAS) Cognitive impairment scales (MMSE)

50 APA DSM IV Criteria Disturbance of consciousness (?arousal) with decreased ability to focus, sustain or shift attention (ARAS). Change in cognition ( memory, dissociation, perceptual disturbance) not better accounted for by pre-established or evolving dementia. Evolves over a short time and fluctuates. Evidence from history, physical exam, or lab. findings judged to be aetiologically relevant.

51 Aetiology Primary brain tumour or metastatic spread to brain (SOL, raised ICP, encephalitis, meningitis) Metabolic failure (liver, lungs, kidneys, heart) (hypercalcaemia, electrolyte balance) Treatment side effects Chemotherapy Steroids BRMs Radiation Opioids IL2 INF Anticholinergics Anti-emetics Infection (UTI, pneumonia, septicaemia) Haematological factors Nutrition (thiamine, nicotinic acid B12) Drug withdrawal (DTs) Paraneoplastic syndromes

52 Chemotherapy Asparaginase Bleomycin Carmustine Cisplatin Fludarabine 5FU Isophosphamide Methotrexate Prednisolone Procarbazine Vinblastine Vincristine

53 Treatment Treat underlying cause(s) Palliate

54 Pharmacological Treatment Haloperidol ( mg titrated to 1-3mg every 8 hours) (but beware EPS, NMS) Other anti-psychotics (D 2 antagonists) Methotrimeprazine in terminally ill?lorazepam ineffective on own

55 Environmental Treatment Safe and supportive environment Reassure family and patient that organic cause Communicate transient or terminal nature Sensory environment quiet and well lit, clock, calendar, familiar people and objects

56 Summary: management Identify, and if possible correct, underlying cause(s) Ensure safety Orientation cues (lighting, clock, familiarity) Remember to support relatives and nurses If necessary, a neuroleptic (e.g. haloperidol [low dose]): beware EPS and NMS

57 Conclusions Delirium is common Grossly under-diagnosed and wrongly diagnosed It is distressing to patients, relatives and staff Potentially reversible

58 Resources Holland JC. Psycho-Oncology. OUP, APOS Web cast (see Useful links in Gelder M, Gath D and Mayou R. The Oxford Textbook of Psychiatry. OUP.

59 Conclusions Psychological and psychiatric morbidity is grossly under-diagnosed in patients with malignant disease. This results in much unnecessary suffering. Much morbidity is preventable. Effective treatments are available.

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