Depression and Medical Co-Morbidities .
and Interventions
Gary Rodin MD FRCPcProfessor of Psychiatry , University of Toronto
Head, Department of Psychosocial Oncology and Palliative CarePrincess Margaret Cancer Centre
What is Depression?
An experience A symptom complex A continuum of distress
disorder a final common pathway
of distress A disorder A neurobiological state
Rodin et al 2009
Medical and Demographic FactorsAge and Gender
Living situation Medical diagnosis and treatment
Personal/family history of psych illness Psychiatric co-morbidity
depression/psychiatric illnessDisease-Related
FactorsBiological Mechanisms
Physical suffering & disability
Stage of diseaseProximity to death
Psychosocial Factors
Social supportAttachment security
Self-esteemSpiritual well-beingEconomic hardshipCaregiving burden
Non-pathological sadness Adjustment disorder Major depression Mild Moderate Severe
Fitzgerald et al 2013
Why is Depression Clinical Important in Medical Populations
Adversely affects: Quality of life
▪ Grassi et al, 1996 Severity of Physical
symptoms▪ Fitzgerald et al 2013
Treatment compliance▪ Colleoni et al, 1996
Will to live▪ Rodin et al, 2007
Family distress ▪ Braun et al, 2007
Health care utilization ▪ Prieto et al, 2002▪ Lo et al, 2011
Detection of Psychological Distress in Medical Settings
Detection by physicians of self-reported distress: 2642 patients in cancer aftercare program in Germany
▪ Mild to severe distress on psychosocial questionnaire detected by physicians in 10% of cases▪ Werner et al 2010
2,325 primary healthcare recipients completed the General Health Questionnaire (GHQ) ▪ Physicians (n=67) identified GHQ-distress in 42 % of
cases Rabinowitz et al 2005
Reason for Low Detection Rate of Depression in Medical Settings
Systemic factors Case volumes Lack of privacy Lack of psychosocial
treatment resources
Medical staff factors Lack of training in
emotional enquiry Lack of time Discomfort with emotions
Patient Factors Perceived stigma/ lack of
interest of medical staff Fear of emotions Lack of awareness
Diagnostic Uncertainty Confounding Symptoms of
depression and medical illness▪ e.g. anorexia, weight loss,
fatigue, sleep disturbance
Proportion of Patients with Metastatic Cancer with Elevated Symptoms of Depression,
Hopelessness and the Desire for Hastened Death
BDI>15 BHS>8 SAHD>905
10152025303540
patientsspouse
Braun et al JCO 2007Rodin et al: SSM 2009 Lo et al JCO 2010l
% ofsample
Depression Hopelessness Desire for Hastened Death
BDI<9 BDI 9-15 BDI 16-21 BDI 22-30 BDI>300
5
10
15
20
25
30
35
40
45
50 46.9
30.9
13.2
7.6
1.4
%Sample
Miller et al Soc Psy Epidemiology 2011
The Distribution of Depressive Symptoms in Patients with Metastatic Cancer
Predicted Depressive Symptoms for Individuals Differing in Physical Burden and
Psychosocial Vulnerability over the last year of life.
Lo C et al. JCO 2010;28:3084-3089Lo et al 2010
Distress Assessment and Response Tool(DART)
Goal:
Administered electronically to cancer outpatients q 2-3 months:
Edmonton Symptom Assessment System (ESAS) for physical symptoms (each visit)• Social Difficulties Inventory (SDI-21) for practical concerns• Patient Health Questionnaire (PHQ-9) for depression• Generalized Anxiety Subscale (GAD-7) for anxiety• Desire for support• Suicidal intention
• Print-out of summary scores for patient and clinic staff
• Response Algorithm
• Download into electronic record
System
Distress Screening Results
Depression Anxiety0
5
10
15
20
25
30
35
Column1Severe
% sample
N- 1215
Bagha ..Li 2012
High sensitivity and specificity of• ESAS-A > 3 for anxiety • ESAS-D>2 for depression
Suicidality in 4822 Ambulatory Patients
Ideation: Thoughts that you would be better off dead, or of hurting
yourself in some way ▪ 5.8% endorsed this item
Intent (in those with ideation) “Is there a chance you would do something to end your life ?”
▪ 7.1% endorsed this item
Leung, Li .. Rodin et al, 2014
Risk Factors for Suicidal Ideation & Intention
Suicidal ideation▪ more recent cancer dx▪ personal or family hx depression ▪ more difficulty making treatment decisions ▪ more social difficulties▪ Symptoms of , anxiety, depression and physical distress
Suicidal intention ▪ male sex▪ difficulty with treatment decisions and self-care
-Leung, Li .. Rodin et al, 2014
Depression & the Disease Specificity Hypothesis
Depression has been postulated to be more common in such diseases as : Cancer, especially pancreatic cancer Cardiac disease Parkinson’s disease Right sided strokes Multiple sclerosis
Evidence Regarding Depression and Medical Disease Specificity
Neurobiological and physical aspects of specific diseases may contribute to depression
BUT-differences in the prevalence of depression across different diseases tend to disappear after controlling for: Stage of disease Severity of physical disability and distress Location of treatment (inpatient vs outpatient) Past personal and psychiatric history Social support
Depression,Disease Progression
&Mortality Cardiac Disease
▪ Increased disease progression and both cardiac and all-cause mortality ▪ Allosaimi & Baker 2012▪ Van Melles et al 2004
Diabetes▪ Increased all-cause mortality
▪ Zhang et al 2005▪ Katon et al 2005▪ Lin et al 2009
Cancer▪ increased mortality in lung cancer
▪ Nakaya, N et al 2008▪ Hamer, M et al 2009▪ Pinquart et al 2010▪ Temel et al 2012
Does Treatment of Depression in Medical Patients improve Survival?
No evidence that treatment of depression with antidepressant medication in cardiac patients reduces mortality in patients with cardiac disease, diabetes or cancer
Mechanisms that contribute to the association of depression and mortality are not clear
Treatment of Depression:
Positive outcomes and sustained improvement are most likely to occur when treatment is directed at etiological and pathogenic factors, rather than solely at symptoms .
▪ Luytens et al, 2006
Psychiatric interventions should address subsystems of variables that are relevant in specific contexts Kendler et al 2008
Preferences Effectiveness of Treatment for Depression in Cancer Patients
Systematic Reviews Psychotherapy as effective as
pharmacotherapy▪ Williams and Dale, 2006▪ Rodin et al , 2007
Psychotherapy preferred to pharmacotherapy with advanced disease▪ Akechi et, 2008
Individual therapy may be more effective than group therapy (not specific to cancer)▪ Cuijpers, 2008
Treatment of Depression in Medical Populations
Tailored psychological interventions are the mainstay of treatment for all patients
Pharmacotherapy should be reserved for patients meeting criteria for psychiatric disorders
Outcomes are improved with collaborative care
Efficacy of Antidepressants in Minor Depression
Based on systematic review & meta-analysis
No clinically important difference between antidepressants and placebo in Rx of minor depression.
Shifting from drugs to psychological interventions requires investment in human resources for training and supervision and delivery of interventions
In systems with no or low resources doctors should still shift away from drug intervention for minor depression as resources may be better spent elsewhere in the health system.
. Barbui et al Brit J Psychiatry 2011
Antidepressant Medication
Sertraline, citalopram, escitalopram are relatively well-tolerated and have the fewest drug-drug interactions
Dual effects may be beneficial e.g. Mirtazepine-weight gain Duloxetine-neuropathic pain relief Venlafaxine-hot flashes
▪ Li, Fitzgerald and Rodin JCO 2013 Psychostimulants have not been shown to relieve
depression though they may have an effect on fatigue
Psychotherapeutic Approaches in Medical Populations
Cognitive-behavioral approaches Relaxation therapy Biofeedback Guided imagery and hypnosis Cognitive Reframing
Supportive-Expressive (psychodynamic) approaches emotional expression, self-understanding, psychological support
The Predictable Problems and Crises of Metastatic
Cancer :Progressive physical disability Complex treatment decisions Disruption in self-concept Fear of dependency Crisis of meaning Fear of death and dying Pressure of time Planning for the end
Managing Cancer and Living Meaningfully (CALM)
Brief semi-structured intervention 3-6 individual sessions 45-60 minutes in length Primary caregiver attends
one or more sessions Delivered over 6 months Semi-structured, with
attention to four domains Delivered by specially
trained mental health professionals
Ongoing weekly supervision seminars
Symptom management& communication with healthcare providers
Thinking of the future, hope, and mortality
Spirituality &sense of meaning/purpose
Changes in self & relations with close others
The Domains of CALMfrom the practical to the profound
Qualitative Outcomes This (CALM) has been the only
opportunity for us to be looked at as people by the medical system. I think that is really important because you are more than the sum of your parts…
I have been able to grow as a person…it makes me feel like I will be able to handle death in a peaceful way.
▪ Nissim et al, Palliative Medicine 2011
Phase II Quantitative Outcomes
Phase II Study Significant reductions in symptoms of :
▪ Depression▪ Distress about death and dying
Significant improvement in spiritual wellbeing
Lo… Rodin, Pall Med 2013
Integrating Mind and Body in Psychiatric Medical Care
.
“The greatest mistake physicians make is that they attempt to cure the body without attempting to cure the mind; yet the mind and the body are one and should not be treated separately!”
Plato428 -367 BCE