Depression Workshop 26 January 2007 Leslie G Walker Professor of Cancer Rehabilitation Donald M Sharp Senior Lecturer in Behavioural Oncology Mary B Walker Senior Clinical and Research Nurse Specialist (Behavioural Oncology)
Depression An unpleasant emotion Associated with the perception of loss A normal feeling A syndrome
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)
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%
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
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
HADS D 6 Study One (CVAP) 6 Study Two CVAP - Docetaxel Mean (SE) 4 2 Mean (SE) 4 2 0 0 Chemotherapy S RT FU4 FU12 Chemotherapy S RT FU4 FU12
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
Assessment 1. Full psychological and social history 2. MSE 3. Predisposing factors 4. Precipitating factors 5. Perpetuating factors
Diagnosis Screening DSM IV criteria Triple criteria (SIP) Psychotic dimension Bipolar dimension Atypical Substance Abuse Grief
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
Depression: Cognitive Suicidal ideation Depressive cognitions (past, present, future) Low self confidence Low self esteem Excessive guilt Memory Concentration Indecisiveness Hypochondriasis Delusions Hallucinations
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
DSM IV Criteria: 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
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
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)
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.
Other Interventions Exercise therapy Bibliotherapy
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
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 www.nelmh.org/home_suicide.asp
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 www.nelmh.org/home_suicide.asp
Conclusions Depression is common, and under treated, in people with cancer Aetiology is often complex and multifactorial Depression can often be prevented Effective treatments are available