Chronology of distress, anxiety, and depression in older cancer aa 2 5 13

Chronology of Distress, Anxiety, and Depression in

Older Cancer Patients

International Workshop on Palliative Care to the Geriatric Oncology Patient

Muscat, Sultanate of Oman,

February 10-13, 2013

James C. Coyne, Ph.D.Department of Psychiatry, University of PennsylvaniaHealth Psychology Program, University of Groningen

Do older cancer patients experience fewer psychological symptoms- anxiety and depression?

Previously answered “of course,” but becoming controversial idea.

Major depression 15%

Anxiety disorders 10%

Dysthymia 3%

• Cancer is less disruptive of social roles such as parenting and employment

• Greater acceptance of mortality, inevitability of end-of-life

• Diagnosis and experience of cancer interpreted in the context of larger physical co-morbidities

Different themes for older cancer patients:

•Patients’ perception of effects on family members: family burden

•Lost opportunity to witness family transitions

•Widowhood and social isolation (important predictors of non-remission of clinical depression)

In general, major depression in the context of a general medical condition has longer episodes and a greater likelihood of relapse and recurrence.

In the case of cancer, attention to depression is often sacrificed to the competing priority of dealing with the cancer, despite the reduction in morbidity that would be achieved by effective treatment of depression.

Depression among cancer patients is associated with: 

•Negative impact on patient’s quality of life

•Reduced acceptance of and compliance with treatment plans

•Prolonged hospitalizations

•Reduced effective coping

•Desire for early death or suicide

Trajectory of adaptation to a diagnosis of cancer and its

treatment

Normal response to diagnosis of cancer is upset, sadness, fright, and worry about the future.

It is difficult to immediately establish whether response is abnormal and when formal psychiatric diagnosis and treatment are appropriate.

Much of initial response to cancer diagnosis is self-limiting or responsive to attention and support and better information.

By six months, residual distress tends to have existed before diagnosis, be tied to non-cancer factors, or reflect neuroticism or psychiatric comorbidity.

Different Patterns of Adjustment

30

35

40

45

50

55

60

65

Diagnosis 3 Months 6 Months

Cut Point

Never Disressed

Resolved Distress

Chronic Distress

Never Distressed 52% of sample; No Elevations over time

Resolved Distress 36% of sample; Elevated distress at diagnosis that resolves by 3 months

Chronic Distress 12% of sample; Elevated distress at all times

Deferred diagnosis of mild mental disorder, supportive action

(stepped diagnosis, stepped care)

On the other hand, be alert to the early emergence of psychiatric disorder, particularly among patients with a past history

•Vegetative symptoms such as psychomotor retardation, extreme insomnia

•Pathological guilt and excessive self-blame

It is controversial whether cancer is associated with psychiatric co-morbidity more than with other physical health conditions.

The challenge is making a diagnosis and ensuring adequate follow up within the competing demands of dealing with a life-threatening condition.

In the case of cancer, attention to depression is often sacrificed to the competing priority of dealing with the cancer, despite the reduction in morbidity that would be achieved by effective treatment of depression.

In general, major depression in the context of a general medical condition has longer episodes and a greater likelihood of relapse and recurrence.

• 25 studies

• Antidepressants more efficacious than placebo at 4-5, 6-8, and 9-18

• Superiority over placebo is apparent within 4-5 weeks and increases with continued use.

Detecting psychiatric morbidity: The argument against routine

screening of cancer patients for depression and anxiety

Effective care for depression requires accurate diagnosis and follow up.

Routine care for depression in general medical settings typically no better than receiving placebo in a clinical trial.

Estimated that 40% of general medical patients receiving treatment for depression achieve no benefit over remaining on waiting list.

Rather than routinely screening patients for depression and placing them in inadequate routine care without follow-up:

•Concentrate on ensuring better follow-up care for known cases of

depression

•Concentrate on patientsat high risk for depression

Be aware of the limitations of common self-report screening instruments:

•Cut points may not hold in another language and culture unless cross validated

•Do not reliably distinguish between anxiety and depression symptoms

•Do not translate well (ex.- butterflies in the stomach)

The Hospital Anxiety and Depression Scale (HADS) should not be used

Coyne JC, van Sonderen E: The Hospital Anxiety and Depression Scale (HADS) is dead, but like Elvis, there will still be citings. Journal of Psychosomatic Research. 73:77-78.

Importance of history psychiatric disorder

Psychiatric disorders tend to be recurrent and episodic, with onset the late teens or early 20s.

Most psychiatric disorders in cancer patients will be recurrences, so past history a good predictor.

Late onset depression is treatable, but less responsive than a recurrence.

• Anhedonia

• Apathy

• Pain, fatigue masqueradingas depressive symptoms

Many depressed patients do not renew prescriptions.

About half require dosage adjustment, medication changes, or education about adherence at five weeks to achieve benefits.

Don't neglect needs of informal caregivers.

Initial symptomatology of women is higher than men, regardless of whether they are patients or spouses.

A key issue in the management of depression among elderly cancer patients is not the availability of efficacious treatments, but ensuring their effective delivery and follow-up.

Collaborative care for depression:

• At least 79 evaluations, 4 with the elderly, 3 with cancer patients

• Interdisciplinary team approach

• Key element is a depression care manager, usually a nurse

• Effect sizes in the range of => .30-.40

Is there an app for this?

Challenge of collaborative care is sustainability, cost of care manager

App decision aids for providers

Cell phone support, remindersfor patients

Thank you!

jcoynester@gmail.com

Follow me on Twitter@CoyneoftheRealm