Screening, assessment & management of Depression and Anxiety

Transcription

1 Screening, assessment & management of Depression and Anxiety Luzia Travado, PhD Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal International Psycho-Oncology Society

2 Impact of Cancer and its multidimensional consequences Emotional and Psychological problems fear, sadness, worries, despair, loss of autonomy and control, change of self-image Physical symptoms and functional problems pain, fatigue, dysfunction, sexual, apetite, sleep, psychosomatic symptoms, disabilities Family and interpersonal uncertainty regarding social roles and tasks, separation from partners, children Patient Social, financial, and occupational strain Responsibility of important social and occupational functions, new dependencies Existential and spiritual problems Confrontation with the mortality of one s own life, search for meaning, consolation; spiritual, religious, philosophical explanations Problems with the health care system impersonal treatment, lack of time, lack of intimacy, terminology hard to understand Koch & Mehnert, IPOS

3 DISTRESS CONTINUUM Normal Distress An unpleasant emotional experience of a psychological, social and/or spiritual nature which extends on a continuum from normal feelings of vulnerability, sadness and fears to disabling problems such as depression, anxiety, panic, social isolation and spiritual crisis. NCCN 1997>2016 Severe Distress adaptation 30-40% Sub-sindrome 15-20% Psychosocial morbidity 45% Worries Fears Sadness Maladjustment Anxiety Depression Adapted from J.Holland, IPOS

4 N=4496 cancer patients before treatment; 35,1% 30-44% (mbc= 42%)

5 Psychosocial Morbidity in Cancer? 35-40%

6 Southern European Psycho-Oncology Study SEPOS Improving Health Staff s Communication and Assessment Skills of Psychosocial Morbidity and Quality of Life in Cancer Patients: a Study in Southern European Countries Cases of Anxiety 34% [HADS] Cases of Depression 24.9% Total of psychological morbidity cases 28.5% No difference across countries (Italy, Portugal, Spain)

7 Epidemiology of Psychological Problems in cancer patients Prevalence rates in empiric studies on mental distress Anxiety disorders Depression Adjustment disorders Post-traumatic stress disorder Screening up to approx. 50%, clinical interview up to approx. 30%, in terminally ill patients up to 80% Screening up to approx. 50%, clinical interview up to approx. 15%, terminally ill patients up to 77% Screening or clinical interview up to approx. 50% (frequently mixed anxiety and depressed mood) Screening or clinical interview up to approx. 30% Cognitive disorders (delirium) Screening or clinical interview up to approx. 85% in terminally ill patients Derogatis 1983, Massie & Holland 1990, Razavi 1990, Bruera et al. 1992, Chochinov et al. 1995, Pereira et al. 1997, van't Spijker et al. 1997, Breitbart & Krivo 1998, Noyes et al. 1998, Sellick & Crooks 1999, Zabora et al. 2001, Kangas et al. 2002, Prieto et al. 2002, Stark et al. 2002, Katz et al. 2003, Osborne et al. 2003, Uchitomi et al. 2003, Akechi et al. 2004, Carlson et al. 2004, Kissane et al. 2004, Grassi et al IPOS online curriculum

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9 Consequences of Psychological Morbidity in Cancer Patients: impact on Clinical outcomes Deterioration of Quality of Life Reduced compliance w/ treatment Less efficacy of chemotherapy Higher perception of pain and other symptoms Shorter survival expectancy Longer hospital stay and increased costs Burden for the family Higher risk of suicide Parker et al., Psychooncology, 2003; Colleoni et al., Lancet, 2000; Walker et al., EJC, 1998; Spiegel et al., Cancer, 1994; Faller et al., Arch Gen Psychiatry, 1999; Watson et al., Lancet, 1999; Pitceathly & Maguire, EJC, 2003; Prieto et al., J Clin Oncol., 2002; Henriksson et al., J Affect Dis, 1995; Grassi et al. 2005; McDaniel et al. 1995, Ehlert 1998, Saupe & Diefenbacher 1999, Linton 2000, Cavanaugh et al. 2001, Härter et al. 2001, Carlson & Bultz, 2004; Watson et al., 2005 adapted from Grassi& Yosuke, IPOS online curriculum:

10 Influence of psychological response (coping) on breast cancer survival: 10-year follow-up of a population-based cohort L Travado Watson M et al. EuropeanJournalof Cancer, 2005

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13 IPOS Statement on Standards and Clinical Practice Guidelines in Cancer Care (updated w/ Lisbon Declaration) Psychosocial cancer care should be recognised as a universal human right; Quality cancer care must integrate the psychosocial domain into routine care; Distress should be measured as the 6 th vital sign after temperature, blood pressure, pulse, respiratory rate and pain. Endorsed by UICC and 75 cancer organizations worldwide

14 Clinical practice guidelines: NCCN Distress Thermometer & Problem List National Comprehensive Cancer Network, 2015

15 A cut-off point > 4 on DT maximized sensitivity (65%) and specificity (70%) for general psychosocial morbidity; A cut-off >5 on DT identified more severe caseness (sensitivity=70; specificity=73%)

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17 Use of the Distress Thermometer in Referral to psycho-oncological interventions NCCN DISTRESS THERMOMETER AND PROBLEM LIST : Treatment Guideline Waiting room Oncology Office Referral Referral Mental Health Brief screening for distress and problem list Assessment by Primary Oncology Team Moderate - Severe distress >5 Social Work Mild distress Pastoral Counseling <5 Oncology Team

18 Steginga, Hutchison, Turner & Dunn, CancerForum March; 30.

19 How to Assess & Manage Depression

20 Primary types of morbidity: from physiological to pathological states Normal sadness Subsyndromal symptoms Reactive depression Clinical depression Normal fears Subsyndromal symptoms Reactive anxiety Anxiety disorder Normal reaction Subsyndromal symptoms Maladaptive coping Adjustment disorders Holland, 1998 (adapted)

21 Assessing Depression (loss) differential diagnosis Demoralization Clinical Depression l l Fluctuating over time Symptoms Sadness Passivity Negative view of future Irritability Respond to help If suicide thoughts present non intense and no plan Persistent(weeks) Symptoms Depressed Mood Lost interest and pleasure Negative viewof self, past and present Worthlessness or guilt Hopelessness-helplessness Suicide thoughts(and/or plans)

22 Symptomsof Depression Mood Depressed mood Loss of interest or pleasure Feelings of hopelessness Feelings of wothlessness Excessive or inappropriate guilt Cognitive symptoms Diminished ability to think or concentrate Memory impairment Recurrent thoughts of death and suicidal ideation Vegetative and somatic symptoms Psychomotor retardation Anorexia and weight loss Sexual disorders (loss of libido) Fatigue or loss of energy Pain Other symptoms (gastrointestinal disorders, headache, tension)

23 Assessing depression in cancer patients When assessing depression in cancer patients evaluate with caution somatic(vegetative) symptoms which could be caused by cancer or treatment rather than depression itself(false positive): Low energy, fatigue Poor appetite or anorexia Weight loss Poor concentration Reduced libido

24 Diagnosis of Major Depression World Health Organization, WHO, ICD Depressive mood Sleep disturbance Decreased appetite Loss of interest Diminished ability to concentrate Worthlessness/ guilt Agitation/ inhibition Suicide Ideation Fatigue IPOS online curriculum

25 Assessment of Depression in cancer IPOS online curriculum Questionnaire Authors Scales / Subscales Item BDI Beck Depression Inventory, BDI-II Beck et al. 1961, 1996 Depression 21 BDI-13 Beck Depression Inventory SF Beck et al BDI-11 Beck Depression Inventory SF Steer et al BDI-PC Beck Depression Inventory PC Beck et al HADS Hospital Anxiety Depression Scale Zigmond & Snaith 1983 Subscale Depression 7 Zung Zung Self-Rating Depression Scale Zung 1965 Depression 20 PHQ Patient Health Questionnaire Spitzer et al Subscale Depression PHQ-9 Patient Health Questionnaire 9 Kroenke et al Depression 9 PHQ-2 Patient Health Questionnaire 2 Kroenke et al Depression 2 BSI-53 Brief Symptom Inventory Derogatis 1975, 1993 Subscale Depression 6 BSI-18 Brief Symptom Inventory 18 Derogatis & Spencer 1982 Subscale Depression 6 Questionnaire Derogatis Authors2000 Scales / Subscales Item CES-D Center for Epidemiologic Studies Depression Scale Radloff 1977 Depression 20 CES-D 5 Center for Epidemiologic Studies Depression Scale 5 Item Version Lewinsohn et al Depression 5

26 HADS Zigmond & Snaith 1983

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28 Standard Treatment for Depression Psychosocial intervention (always) Individual Psychological Treatment Group Psychotherapy Psychopharmacological intervention (as needed) Drugs with antidepressant properties (ADs)

29 Li, Fitzgerald & Rodin. Evidence-based Treatment of DEPRESSION in Cancer Patients. JCO 2012, 30:

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31 How to Assess & Manage Anxiety

32 Assessment of Anxiety symptoms and Anxiety Disorders in cancer Anxiety is generated when someone interprets there is a threatto own integrity or that of loved ones (e.g., disease, treatment procedures, surgery, chemo, etc.) The primary symptoms are somatic symptoms: increased heart rate, shortness of breath, sweating, feelings of anxiety, dizziness, lightheadedness, paresthesiaand nausea, problems concentrating, nervousness, and inner tension and irritableness. Cognitive symptoms: fear of loss of control, fear of going crazy, fear of dying, feelings of irreality, catastrophic thoughts, and constant brooding fear of recurrence Panic disorders (with or without agoraphobia), generalized anxiety disorders, and less frequently phobic fears

33 Assessment of Anxiety and Anxiety Disorders in cancer IPOS online curriculum Questionnaire Authors Scales / Subscales Item HADS Hospital Anxiety Depression Scale Zigmond & Snaith 1983 Subscale Anxiety 7 SAS Zung Self-Rating Anxiety Scale Zung 1971 Anxiety 20 PHQ Patient Health Questionnaire Spitzer et al Subscale Panic Disorder, Anxiety Symptoms BSI-53 Brief Symptom Inventory BSI-18 Brief Symptom Inventory 18 Derogatis 1975, 1993 Derogatis 2000 Subscale Anxiety Subscale Anxiety STAI State-Trait Anxiety Inventory Spielberger et al State Anxiety Trait Anxiety SAI State Anxiety Index Sesti 2000 State Anxiety 20 FOP-Q Fear of Progression Questionnaire Dankert et a. 2003, Herschbach, 2003 MAX-PC Memorial Anxiety Scale for Prostate Cancer Roth et al Fear of Progression subscales Prostate Cancer Anxiety Fear of Progression PSA Anxiety

34 HADS Zigmond & Snaith 1983

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36 Traeger et al. Evidence-based Treatment of ANXIETY in Patients with Cancer. JCO 2012, 30:

37 Mixed states: depression and anxiety difficult to have pure states, since anxiety and depression often overlap An estimated 60 to 80% of patients with clinical depression also have symptoms of anxiety and vice versa, anxiety disorders may complicate with depression Anxious depressed patients have more severe symptoms, reduced response to conventional therapy and poorer quality of life

38 Psychological Intervention Cognitive-behavioral Intervention [Greer et al., BMJ, 1992] Supportive-Expressive Therapy [Classenet al., Arch Gen Psychiatry 2001] Cognitive-Existential Group Therapy [Kissaneet al., Psycho-Oncology, 2003] Dignity Therapy [Chochinov et al, Lancet Oncol. 2011] Meaning-centered psychotherapy [Breitbart et al., JCO, 2015] CALM Managing Cancer & Living Meaningfully [Rodin group, Pal Med,2011, BMC 2015]

39 Conclusion: MBSR shows a moderate to large positive effect size on the mental health of breast cancer patients, further systematic investigation because it has a potential to make a significant improvement on mental health for women in this group.

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41 Canadian (CAPO) Guidelines Fitch, Porter & Page, 2008 (adapted with permission)

42 Psycho-oncology services provide effective (evidence-based, RCT s) interventions for: (a) preventing or reducing the distress and psychosocial morbidity associated w/ cancer (b) improving patients skills to cope with the demands of treatment and the uncertainty of the disease (c) improving their Quality of Life (d) improving clinical outcomes Integration of Psychosocial Oncology Care in Routine Oncology IPOS - Luzia Travado Psychosocial Oncology Care is an important element of high-quality care >> And are cost effective as well as general health costs reductive

43 Conclusions Distress, Depression and Anxiety are frequent in cancer patients They have negative consequences on patients clinical outcomes Distress should be routinely screened and psychosocial needs psychosocial care routinely offered to all patients and referrals to specialized care as needed Psychosocial Care Guidelines should be used to treat psychological problems in a comprehensive way Multidisciplinary team with trained staff in psychosocial care to address psychosocial needs

44 IPOS Online Curriculum A Program in Psycho-Oncology, developed by the International Psycho-Oncology Society and the European School of Oncology Depression and Depressive Disorders in Cancer Patients Luigi Grassi, M.D. Section of Psychiatry, University of Ferrara, Ferrara, Italy Yosuke Uchitomi, M.D., PhD Psycho-Oncology Division, National Cancer Center Research Institute East, Kashiwa, Japan IPOS Online Curriculum IPOS Online Curriculum A Program in Psycho-Oncology, developed by the International Psycho-Oncology Society and the European School of Oncology Anxiety and Adjustment Disorders in Cancer Patients Katalin Muszbek, M.D. Medical Director, Hungarian Hospice Foundation Budapest, Hungary A Program in Psycho-Oncology, developed by the International Psycho-Oncology Society and the European School of Oncology Psychosocial Assessment in Cancer Patients Anja Mehnert, PhD Uwe Koch, MD, PhD Institute of Medical Psychology, University Medical Center Hamburg-Eppendorf Hamburg, Germany

45 IPOS ESO Online Curriculum Multilingual Curriculum on Psychosocial Aspects of Cancer Care (English, French, German, Hungarian, Italian, Spanish, Portuguese, Chinese, Japanese) Communication and Interpersonal Skills in Cancer Care by Walter Baile, MD (USA) Anxiety and Adjustment Disorders in Cancer Patients by Katalin Muszbek, MD (Hungary) Distress Management in Cancer Patients by Jimmie C. Holland, M.D, USA Depression and Depressive Disorders in Cancer Patients by Luigi Grassi, MD (Italy) and Yosuke Uchitomi, MD, P.D (Japan) Psychosocial Assessment in Cancer Patients by UweKoch, MD, PhD & AnjaMehnert, PhD (Germany) Cancer: A Family Affair by Lea BaiderPhD (Israel) Loss, Grief and Bereavement by David Kissane MD (Australia) Palliative Care for the Psycho-Oncologist by William Breitbart MD (USA) Ethical Implications of Psycho-Oncology by Antonella Surbone MD, PhD, FAC (Italy) Psychosocial Interventions: Evidence and Methods for Supporting Cancer Patients by Maggie Watson PhD and Barry Bultz PhD (UK, Canada) Luzia Travado

46 THANK YOU Luzia Travado, PhD Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal International Psycho-oncology Society Luzia Travado, PhD Lisbon, Portugal Head of Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal International Psycho-oncology Society, President