The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

Education in Palliative and End-of-life Care - Oncology

The

ProjectEPEC-OTM

EEPPEECC

OO Module 3hModule 3h

Symptoms –Symptoms –DepressionDepression

EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

Depression . . . Depressed moodDepressed mood Anhedonia – loss of interest or Anhedonia – loss of interest or

pleasurepleasure > 2 weeks> 2 weeks

. . . Depression . . . IrritabilityIrritability Changes in Changes in

Appetite or weightAppetite or weightSleepSleepPsychomotor activityPsychomotor activity

Decreased energyDecreased energy Worthlessness, helplessness, Worthlessness, helplessness,

hopelessnesshopelessness GuiltGuilt

. . . Depression Difficulty thinking, concentrating, Difficulty thinking, concentrating,

making decisionsmaking decisions Suicidal ideation or wishes to hasten Suicidal ideation or wishes to hasten

deathdeath Somatic symptoms often not helpful Somatic symptoms often not helpful

in this populationin this population

Risk factors . . . Poorly controlled painPoorly controlled pain Progressive physical impairmentProgressive physical impairment Advanced diseaseAdvanced disease MedicationsMedications

SteroidsSteroidsChemotherapeuticsChemotherapeutics

. . . Risk factors Particular diseasesParticular diseases

Pancreatic, breast, lung, mets to Pancreatic, breast, lung, mets to nervous systemnervous system

Younger ageYounger age Spiritual painSpiritual pain Risk factors in general populationRisk factors in general population

Prior Hx, family Hx, social stressPrior Hx, family Hx, social stressSuicide attempts, substance useSuicide attempts, substance use

Prevalence Up to 58 % of cancer patientsUp to 58 % of cancer patients

Prognosis Untreated, associated with poor Untreated, associated with poor

prognosisprognosis Knowledge of true extent of disease Knowledge of true extent of disease

and prognosis do no lead to and prognosis do no lead to depression or adverse outcomesdepression or adverse outcomes

Key points

1.1. PathophysiologyPathophysiology

2.2. AssessmentAssessment

3.3. ManagementManagement

Pathophysiology Involved neurotransmittersInvolved neurotransmitters

NorepinephrineNorepinephrineSerotoninSerotoninDopamineDopamine

GeneticsGenetics Environmental influencesEnvironmental influences

Assessment . . . Assess for signs and symptoms Assess for signs and symptoms

noted abovenoted aboveDo you feel depressed most of the time?Do you feel depressed most of the time?

Family observationsFamily observations Screening toolsScreening tools

. . . Assessment Differentiate betweenDifferentiate between

Grief reactionsGrief reactionsAdjustment disordersAdjustment disordersDelirium, particularly hypoactiveDelirium, particularly hypoactiveDementiaDementia

Consult with mental health Consult with mental health professionalsprofessionals

Suicide Suicidal thoughts are a sign of Suicidal thoughts are a sign of

depressiondepression Discussion may reduce the riskDiscussion may reduce the risk Assess all depressed patients for riskAssess all depressed patients for risk

Have you ever thought of committing Have you ever thought of committing suicide?suicide?

Do you have a plan?Do you have a plan? High risk if recurrent thoughts, plans High risk if recurrent thoughts, plans

Management CounselingCounseling Complementary therapiesComplementary therapies PharmacotherapyPharmacotherapy Combinations are bestCombinations are best Lack of improvement within weeks Lack of improvement within weeks

suggests more aggressive therapy or suggests more aggressive therapy or psychiatry consult neededpsychiatry consult needed

Counseling Weave into routine interventionsWeave into routine interventions

Include family when possibleInclude family when possible Improve patient understandingImprove patient understanding Create a different perspectiveCreate a different perspective Identify strengths, coping strategiesIdentify strengths, coping strategies New coping strategiesNew coping strategies

Complementary therapies RelaxationRelaxation Distraction Distraction Guided imageryGuided imagery MeditationMeditation Massage therapyMassage therapy AromatherapyAromatherapy Self-hypnosisSelf-hypnosis

ExerciseExercise SunlightSunlight

Pharmacotherapy . . .

Tricyclic antidepressantsTricyclic antidepressants SSRIsSSRIs

Preferred as less adverse effectsPreferred as less adverse effects PsychostimulantsPsychostimulants Other antidepressantsOther antidepressants

. . . Pharmacotherapy Choose by time to effectChoose by time to effect

Days – psychostimulantsDays – psychostimulantsWeeks / months – SSRIs, other Weeks / months – SSRIs, other

antidepressantsantidepressants Start dosing low, titrate slowly Start dosing low, titrate slowly Consider consultationConsider consultation

Tricyclic antidepressants Not first-line therapy when SSRIs Not first-line therapy when SSRIs

available, unless looking foravailable, unless looking forAnalgesic or sleep altering effectsAnalgesic or sleep altering effects

Latency 3 – 6 weeksLatency 3 – 6 weeks Adverse effects are commonAdverse effects are common

Anticholinergic, cardiacAnticholinergic, cardiacNortriptyline, desipramine have fewer Nortriptyline, desipramine have fewer

adverse effectsadverse effects

SSRIs Latency 2 – 4 weeksLatency 2 – 4 weeks Highly effective Highly effective Well toleratedWell tolerated Once-daily dosingOnce-daily dosing Lower doses may be effective in Lower doses may be effective in

advanced illnessadvanced illness Check for drug-drug interactionsCheck for drug-drug interactions

Psychostimulants . . . Rapid effect in hours to daysRapid effect in hours to days Minimal adverse effectsMinimal adverse effects Alone or in combination with SSRIsAlone or in combination with SSRIs Can continue indefinitely Can continue indefinitely Tolerance may not be a factorTolerance may not be a factor Diminish opioid induced sedationDiminish opioid induced sedation

. . . Psychostimulants May exacerbateMay exacerbate

TremulousnessTremulousnessAnxietyAnxietyAnorexiaAnorexiaInsomniaInsomnia

ChooseChooseMethylphenidateMethylphenidateDextroamphetamineDextroamphetaminePemolinePemolineModafinilModafinil

Other antidepressants May be particularly helpful for:May be particularly helpful for:

Sedation (mirtazapine, trazodone)Sedation (mirtazapine, trazodone)Energy (bupropion, venlafaxine)Energy (bupropion, venlafaxine)Appetite stimulation (mirtazapine)Appetite stimulation (mirtazapine)

Still being studied in this populationStill being studied in this population

Summary . . . Very commonVery common Intense sufferingIntense suffering Not inevitableNot inevitable Treatable in most cases, with Treatable in most cases, with

multiple approachesmultiple approaches Early treatment is betterEarly treatment is better

EEPPEECC

OO

. . . Summary

Use comprehensive Use comprehensive assessment and assessment and

pathophysiology-based therapy pathophysiology-based therapy

to treat the cause and improve to treat the cause and improve the cancer experiencethe cancer experience