Assessment & Management of Depression in Palliative Care

Transcription

1 Florence s Story Assessment & Management of Depression in Palliative Care Carla Jolley, MN, ARNP, ANP-BC, AOCN, ACHPN Palliative Care APN WhidbeyHealth Palliative Care Consult Team Ralph s Story Incidence/Prevalence REPORTED PREVALENCE OF MAJOR DEPRESSIVE DISORDER IN PALLIATIVE CARE SETTINGS IS 15% CANCER 40% CONGESTIVE HEART FAILURE 9% CHRONIC OBSTRUCTIVE PULMONARY DISEASE 38% CHRONIC KIDNEY DISEASE 45% HIV INFECTION 48% STROKE 35%-50% PARKINSONS DISEASE 40% MULTIPLE SCLEROSIS 40% CHRONIC PAIN SYNDROME 30-54% DIABETES 25% CORONARY ARTERY DISEASE 18-20% DEMENTA

2 What makes it so complicated??????? Mood Sadness Grief Depressive symptoms Depressive episode Depressive disorder NORMAL SADNESS Feelings of connection with others Feeling that sadness will end some day Able to enjoy happy memories Feelings of self-worth Sadness comes in waves Able to look forward to things Able to experience pleasure Desire to live DEPRESSION Feelings of being outcast and alone Feelings sadness is permanent Feelings of regret and rumination on irredeemable mistakes Extreme self-depreciation and self-loathing Sadness is constant and unremitting No hope or interest in the future Enjoyment of only a few activities Suicidal thoughts or behaviors Differentiating grief from depression in seriously ill patients 1) Grief and depression share common symptoms and my coexist 2) Many of the somatic symptoms traditionally used to diagnose depression may be present as part of the serious illness process or due to grief 3) The affective changes used to identify depression (sadness, crying) are also seen in grief 4) There is a common misperception that depression is universal and normal phenomenon in seriously ill population Periyakoil et al (2012) Characteristic Normal Grief Depression Nature of Response Adaptive Maladaptive Focus of distress Distress is in response to a particular Distress is pervasive and affects all loss and does not affect all aspects of aspects of life life Symptom fluctuations Comes in waves but generally improves Constant with time Mood Sadness and dysphoria Protracted and constant depression or flat affect Interests/capacity for pleasure Intact, although engagement in Anhedonia with markedly diminished activities may be diminished because of interest or pleasure in all activities functional decline Hope Episodic and focal loss, hopes may Hopelessness is persistent and change over time, positive orientation pervasive towards the future Self-worth Maintained, although feelings of Worthlessness with feeling that one s helplessness are common life has no value Guilt Regrets and guilt over specific event Excessive feelings of guilt Suicidal ideation Passive and fleeting desire for hastened Preoccupation with desire to die death 2

3 Assessment of symptoms of major depression in adults include Depressed mood for most of the day on most days Diminished pleasure or interest in most activities Social withdrawal Feelings of worthlessness, hopelessness, and helplessness Recurrent thoughts of death or suicide Inappropriate guilt Some symptoms of depression may be due to underlying disease Change in appetite or weight gain Sleep pattern changes Fatigue/reduced energy Pain Psychomotor slowing Loss of libido Diminished concentration Other assessment parameters Medication History Past Medical History: pain, metabolic imbalances, endocrine abnormalities Family history of depression and efficacy of treatments Social history: triggers of depression or anxiety, significant loss, abuse, traumas, financial difficulties, smoking Suicidal evaluation 1) Has anyone close to you attempted or completed suicide? 2) Have you ever tried to hurt yourself? 3) Are you currently thinking about hurting yourself? 4) Do you have a plan? 5) How are you planning on doing it? 6) Do you have means to implement such a plan? 3

4 DSM-5 Criteria DX: Major Depressive Disorder Entails presence of > 5 of following symptoms (including at least 1 of the first 2 core symptoms) for > 2 weeks tht is change from usual function and causes clinically significant distress or impairment in social, occupation, or other area of life Depressed mood Significantly decreased interest or pleasure in almost all activities Significant change in weight or appetite Insomnia or hypersomnia Psychomotor agitation or retardation nearly every day (observable by others) Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Indecisiveness or decreased ability to concentrate Recurrent thoughts of death or suicide DSM Symptoms of Major Depression and Substitutions Proposed by Endicott DSM CRITERIA Poor appetite or changes in weight Loss of energy fatigue or psychomotor retardation or agitation Insomnia or hypersomnia Feellng of worthlessness or excessive guilt or diminished ability to think or concentrate ENDICOTT S SUBSTITUTIVE CRITERIA Tearfulness or depressed appearance Brooding, self-pity, pessimism Social withdrawal Lack of reactivity, cannot be cheered up Screening & Assessment Tools 1. During the past month, have you been bothered by feeling down, depressed, or hopeless? 2. During the past month, have you often been bothered by little interest or pleasure in doing things? YES=Positive Screen Validated 100% sensitivity and 78% specificity compared to DSM-IV (Rao 2011) ARE YOU DEPRESSED? Validated at 0.85 specificity and low false negative rate (Taylor 2013) Other screening instruments SCALE NUMBER OF ITEMS COMMENTS Hospital Anxiety and Depression Scale (HADS) 14 Originally developed to assess in hospitalized patient. Focuses on cognitive symptoms. Validated in PC population PHQ-9 9 Easy to administer and score, does have physical symptoms weighted 1/3. Beck Depression Inventory 21 Each answer scored 0-3, high burden for patient Geriatric Depression Scale 15 on short form Problems with validity with dementia Zung Depression Scale Distress Thermometer 20 item 4

5 Florence Ralph Pharmacology Expected survival relative to time effect of medication Integrated Therapy Cognitive Behavior Therapy Patient Symptom management Patient & Family Education If expected survival > than several months, consider conventional antidepressants, which may have time to effect > several weeks If expected survival < several weeks, consider rapid-acting psychostimulants If expected survival < several days, consider sedatives or opioids to relieve distress Psychotherapy 5

6 SSRI s SNRI s Atypical Citalopram (Celexa) Desvenlafaxine (Pristiq) Bupropion (Wellbutrin) Escitalopram (Lexapro) Duloxetine (Cymbalta Mirtazipine (Remeron) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) TRICYCLIC ANTIDEPRESSANTS Desipramine (Norpramin) Nortriptyline (Pamelor) Venlafaxine (Effexor) STIMULANTS Methylphenidate (Ritalin) Destroamphetamine (Dexidrine) Side Effects SSRIs Agitation Anorexia Constipation Diarrhea Discontinuation syndrome Dizziness Dry mouth Headache Insomnia Nausea Sexual dysfunction Somnolence Sweating Tremo SNRIs Agitation Constipation Discontinuation syndrome Dry mouth Fatigue Headache Hypertension (dose related) Nausea Sleep disturbance Sweating Tremor Psychotherapy Goals Normalizing emotional distress Facilitate expression of fears and concerns Providing realistic reassurance and support Bolstering existing strengths and coping skills Multiple models Life review Reminiscence therapy Dignity Therapy Psycho-education therapy Cognitive behavioral therapy Problem Solving 6

7 Integrative Therapy Mindfulness Guided Imagery Music Therapy Massage Supplements: St. John s Wort, Omega 3 s, SAMe Using the Team: Nursing Assure physical symptoms are controlled Provide ongoing education related to medications and illness progression Collaborate with team to support interventions Provide ongoing assessment back to the team Encourage and support care plan Using the Team: Social Work Patient and family counseling: psychotherapy, sex counseling, or grief counseling Suicidal evaluation/intervention Problem solving teaching Caregiver issues Using the Team: Chaplaincy Assessment/Intervention Grief Concerns about death and afterlife Conflicted or challenged belief systems Loss of faith Concerns about relationship with deity Isolation from religious community Guilt Hopelessness Conflict between religious beliefs and recommended treatment Ritual needs Spiritual counseling Reading materials Prayer Rituals 7

8 Ralph s Care Plan Florence s Care Plan Depression: Disease Specific Cancer COPD ESRD Dementia Heart Failure Parkinson s References Blatt, L. Psychosocial Aspects. HPNA Core Curriculum for the Advanced Practice Hospice and Palliative Nurse Chovan,J. (2016) Depression and Suicide. Advanced Practice Nursing. Dahlin, C. ED. Oxford Press Dynamed. Depression in palliative care patients. Downloaded Exline, J. et al. (2012) Forgiveness, Depressive Symptoms, and Communication at End of Life: A Study with Family Members of Hospice Patients. Journal of Palliative Medicine Vol 15 (10) McCabe,M et al. (2012) Detecting and Managing Depressed Patients: Palliative Care Nurses Self-Efficacy and Perceived Barrier to Care. Journal of Palliative Medicine. Vol 15 (4) National Comprehensive Cancer Network (NCCN) Distress Guidelines downloaded Noorani, N., & Montagnini, M. (2007) Recognizing Depression in Palliative Care Patients. Journal of Palliative Medicine Volume 10 (2) Pasacreta,J., Minarik, P. & Nield-Anderson, L. Anxiety and Depression Oxford Textbook of Palliative Nursing. Pereira, J. & Bruera, E. (2001) Depression and Psychomotor Retardation: Diagnostic Challenges and the Use of Psychostimulants. Journal of Palliative Medicine. Vol 4 (1) Periyakoil., V., Kraemer, H., & Noda, A. (2012) Measuring Grief and Depression in Seriously Ill Outpatients Using the Palliative Grief Depression Scale. Journal of Palliative Medicine Vol 15 (12) Rao, S., Ferris, F, & Irwin, S. (2011). Ease of Screening for Depression and Delirium in Patients Enrolled in Inpatient Hospice Care. Journal of Palliative Medicine 14 (3), Rosenberg,l. & Thomas, J. (2016) Pharmacologic Management of Depression in Advanced Illness #309. Journal of Palliative Medicine Vol 19(7) Taylor,l et al. (2013) Diagnosis of Depression in Patients Receiving Specialist Community Palliative Care: Does Using a Single Screening Question Identify Depression Otherwise Diagnosed by Clinical Interview?. Journal of Palliative Medicine Vol 16(9) p UptoDate. Unipolar Major Depression in Adults: Choosing Initial Treatment. Downloaded 8/21/2016 Widera, E. & Block, S. (2012) Managing Grief and Depression at the End of Life. Downloaded from American Family of Physican Web Site at 8