Dr. Catherine Mancini and Laura Mishko
Interviewing Depression, with case study Screening When it needs treatment Anxiety, with case study Screening When it needs treatment
Observation Asking questions sensitively Sometimes people tell me. Picking up on ESAS scores Information from significant others People will often reveal their important information at the end of a conversation, so be most alert at the end of an interaction
Mrs. Jones Comes to her clinic appointment alone and scores 9/10 for depression on ESAS Due to get the results of her scan today States always emotional at follow ups Staff note she is crying
Mr. Brown Arrives for clinic appointment late Has lost weight since last appointment History of depression Does not want to do ESAS Irritable with volunteer staff
Persistent sadness, irritability or low mood
Marked loss of interest or enjoyment in activities
Disturbed sleep Change in appetite or 5% weight change Loss of energy
Poor concentration or indecisiveness Feelings of worthlessness or excessive/inappropriate guilt Agitation or slowing of movement
Recurrent thoughts of death Life is not worth living This can progress into thoughts and plans of suicide
Five of the above symptoms with at least one of these a core symptom The symptoms cause you distress and impair functioning (work relationships) Symptoms occur most of the time, on most days and have been present for at least two weeks The symptoms are not due to a medical condition or to drug or alcohol use
Depression that started as a child/teen Abuse of alcohol or other drugs History of an anxiety disorder Certain personality traits low self esteem Serious or chronic illness Traumatic life events Family history
Patient Health Questionnaire (PHQ 9) Geriatric Depression scale (GDS)
SIGECAPS + Mood 2001 American Academy of Family Physicians
S Sleep I Interest G Guilt or worthlessness E Energy C Concentration A Appetite P Psychomotor S Suicide
Not diagnostic In the oncology population, somatic symptoms can be treatment/disease related Focus on brooding, hopelessness, fearfulness and self pity
Mrs. Jones Comes to her clinic appointment alone and scores 9/10 for depression on ESAS Due to get the results of her scan today States always emotional at follow ups Staff note she is crying
Mr. Brown Arrives for clinic appointment late Has lost weight since last appointment History of depression Does not want to do ESAS Irritable with volunteer staff
Screening tool Clinical interview/assessment Important to treat depression in the oncology population as it is not normal to be depressed
Studies have reported the prevalence of depression among cancer patients to be as high as 40% Less is known about the prevalence of anxiety disorders Rates of anxiety disorder reported between 0.9 49%
75% of patients with depression will have a comorbid anxiety disorder 79% of patients with an anxiety disorder will have a depressive disorder
Most patients diagnosed with cancer will experience anxiety Many issues are out of their control Work Finances Relationships Treatment effects Fear of recurrence Prognosis
Important to recognize when anxiety becomes pathological Disproportionate to the threat Duration of the symptoms Meets diagnostic criteria with interference
Excessive anxiety Fear Worry Avoidance Multiple somatic complaints Vague pains, headaches, dizziness, GI complaints Sleep disturbance Fatigue Poor concentration Substance use
Family history of anxiety Personal history of anxiety in childhood and adolescence, including excessive shyness Stressful life event and/or traumatic event Being female Comorbid psychiatric disorder, especially depression, ADHD, substance disorder(s)
Anxiety becomes a problem, and a disorder should be considered when: It is of a greater intensity and (or) duration than usually expected, given the circumstances of its onset (consider context of family, societal, and cultural behaviour and expectations) It leads to impairment or disability in occupational, social, or interpersonal functioning Daily activities are disrupted by the avoidance of certain situations or objects in an attempt to diminish the anxiety It includes clinically significant, unexplained physical symptoms and (of) obsessions, compulsions, and intrusive recollections or memories of trauma (unexplained physical symptoms, intrusive thoughts, and compulsion like behaviours are very common among people who do not have an anxiety disorder) The Canadian Journal of Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders. Cdn J Psychiatry 2006;51 (Suppl 2): 1S 90S.
1) Panic Disorder 2) Generalized Anxiety Disorder 3) Social Anxiety Disorder 4) Obsessive Compulsive Disorder 5) Post Traumatic Stress Disorder
Panic Disorder (PD) Have you ever had a spell or attack where all of a sudden you felt frightened, anxious, or uneasy? Ever had a spell or attack when for no reason your heart began to race, you felt faint or nauseous or could not catch your breath?
Generalized Anxiety Disorder (GAD) Have you been bothered by nerves or feeling anxious or on edge for at least 6 months? Do you worry excessively and have trouble stopping or controlling the worry? Would people describe you as a worrier?
Social Anxiety Disorder (SAD) Have you had a problem being anxious or uncomfortable around people? Does fear of embarrassment cause you to avoid doing things or speaking to people? Is being embarrassed or looking stupid among your worst fears?
Obsessive Compulsive Disorder (OCD) Do you experience unwanted recurrent and intrusive thoughts that cause anxiety but you cannot control? (e.g., thoughts about contamination, doubts about your actions, aggressive thoughts, etc.) Do you perform repetitive behaviours (or mental acts) in order to decrease the anxiety generated by the obsessions? (e.g., checking, washing, counting, or repeating)
Post Traumatic Stress Disorder (PTSD) Have you had recurrent dreams or nightmares of trauma, or avoidance of trauma reminders?
In the last three months, have you Had 5 or more drinks on any one occasions? Used an illegal drug (including marijuana)? Used a prescription medication for nonmedical reasons?
For Generalized Anxiety Disorder: 5 9 mild anxiety 10 14 moderate anxiety 15 21 severe anxiety
Moderately good at screening for panic disorder, social anxiety disorder and PTSD When screening for individual or any anxiety disorder, a score of 10 or greater is recommended
54 year old unemployed married female Diagnosis of Stage III B cancer of the right breast in 2011 Chemotherapy and right modified mastectomy with axillary node dissection Radiation treatment completed in November 2011 Referred for assessment of depressive and anxiety symptoms
Long history of feeling depressed and anxious but no formal psychiatric history Reported low mood with anhedonia, disinterest Initial and intermittent insomnia Poor appetite Poor energy level always exhausted Decreased ability to concentrate Passive suicidal thoughts
History of panic attacks Symptoms of increased heart rate, shortness of breath, shaking, hot flushes, feeling she will pass out claustrophobic Avoids crowds, elevators, malls, using public transportation
Excessive worries Worries about her health, husband s health, her animals, her sister, financial problems, being late, etc. Can t control worry Muscle tension, irritability, decrease concentration, sleep difficulties when worrying
Symptoms of OCD Doubting thoughts leading to excessive checking of doors, electrical appliances Frequent need for reassurance Obsesses about bad things happening Excessive cleaning Likes things in their right place
Pulls hair from the front of her scalp and eyebrows since childhood Does not feel comfortable if hair touches the skin on her forehead so pulls it out Pulls out grey hair and hair with a particular texture Feels unable to control hair pulling
Diagnosis Major Depression Panic Disorder with Agoraphobia Obsessive Compulsive Disorder Generalized Anxiety Disorder Trichotillomania
1) Anxiety disorders are often comorbid with depression and frequently diagnosed in patients with cancer 2) Important to distinguish between normal anxiety/worry and pathological anxiety disorder 3) A simple screening tool is available to help decide who requires further assessment