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