Screening, assessment & management of …...Screening, assessment & management of Depression and...
Transcript of Screening, assessment & management of …...Screening, assessment & management of Depression and...
Screening, assessment & management of Depression and Anxiety
Luzia Travado, PhD
Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal
International Psycho-Oncology Society
Patient
�
Emotional and Psychological
problems
fear, sadness, worries, despair, loss
of autonomy and control, change
of self-image
Problems with the health
care system
impersonal treatment, lack of time,
lack of intimacy, terminology hard
to understand
Physical symptoms and
functional problems
pain, fatigue, dysfunction, sexual,
apetite, sleep, psychosomatic
symptoms, disabilities
Impact of Cancer and its
multidimensional consequences
Family and interpersonal
uncertainty regarding social roles and
tasks, separation from partners,
children
Social, financial, and
occupational strain
Responsibility of important social
and occupational functions, new
dependencies
Existential and spiritual
problems
Confrontation with the mortality of
one’s own life, search for meaning,
consolation; spiritual, religious,
philosophical explanations
Koch & Mehnert, IPOS 2005
www.ipos-society.org
DISTRESS CONTINUUM
Sub-sindrome
15-20%
Normal
Distress
adaptation
30 - 40%
Worries
Fears
Sadness
Severe
Distress
Psychosocial morbidity
45%
Maladjustment
Anxiety
Depression
Adapted from J.Holland, IPOS 2005
www.ipos-society.org
An unpleasant emotional experience of a psychological,
social and/or spiritual nature which extends on a continuum
from normal feelings of vulnerability, sadness and fears to
disabling problems such as depression, anxiety, panic, social
isolation and spiritual crisis. NCCN 1997>2016
N=4496 cancer patients before treatment; 35,1%
(mBC= 42%)
30-44%
Psychosocial Morbidity
in Cancer
35-40%
?
� Cases of Anxiety � 34% [HADS]
� Cases of Depression � 24.9%
� Total of psychological morbidity cases � 28.5%
� No difference across countries (Italy, Portugal, Spain)
Improving Health Staff’s Communication and Assessment Skills
of Psychosocial Morbidity and Quality of Life in Cancer Patients:
a Study in Southern European Countries
Southern European
Psycho-Oncology Study – SEPOS
Epidemiology of Psychological Problems in cancer patients
Anxiety disorders
Depression
Adjustment disorders
Cognitive disorders (delirium)
Screening up to approx. 50%, clinical interview up to approx. 30%, in terminally ill patients up to 80%
Screening up to approx. 50%, clinical interview up to approx. 15%, terminally ill patients up to 77%
Screening or clinical interview up to approx. 50% (frequently mixed anxiety and depressed mood)
Post-traumatic stress disorder
Prevalence rates in empiric studies on mental distress
Screening or clinical interview up to approx. 30%
Screening or clinical interview up to approx. 85% in terminally ill patients
Derogatis 1983, Massie & Holland 1990, Razavi 1990, Bruera et al. 1992, Chochinov et al. 1995, Pereira et al. 1997, van't Spijker et al. 1997, Breitbart & Krivo
1998, Noyes et al. 1998, Sellick & Crooks 1999, Zabora et al. 2001, Kangas et al. 2002, Prieto et al. 2002, Stark et al. 2002, Katz et al. 2003, Osborne et al. 2003,
Uchitomi et al. 2003, Akechi et al. 2004, Carlson et al. 2004, Kissane et al. 2004, Grassi et al. 2005IPOS online curriculum
www.ipos-society.org
http://canceraustralia.gov.au/sites/default/files/publications/pca-1-clinical-practice-
guidelines-for-psychosocial-care-of-adults-with-cancer_504af02682bdf.pdf
Consequences of Psychological Morbidity in Cancer Patients: impact on Clinical outcomes
� Deterioration of Quality of Life
� Reduced compliance w/ treatment
� Less efficacy of chemotherapy
� Higher perception of pain and other symptoms
� Shorter survival expectancy
� Longer hospital stay and increased costs
� Burden for the family
� Higher risk of suicide
Parker et al., Psychooncology, 2003; Colleoni et al., Lancet, 2000; Walker et al., EJC, 1998; Spiegel et al., Cancer, 1994; Faller et al., Arch Gen Psychiatry, 1999; Watson et al., Lancet, 1999; Pitceathly & Maguire, EJC, 2003; Prieto et al., J Clin Oncol., 2002; Henriksson et al., J Affect Dis, 1995; Grassi et al. 2005; McDaniel et al. 1995, Ehlert 1998,
Saupe & Diefenbacher 1999, Linton 2000, Cavanaugh et al. 2001, Härter et al. 2001, Carlson & Bultz, 2004; Watson et al., 2005
adapted from Grassi & Yosuke, IPOS online curriculum: www.ipos-society.org
L Travado
Influence of psychological response (coping) on breast cancer survival:10-year follow-up of a population-based cohort
Watson M et al. European Journal of Cancer, 2005
IPOS Statement on Standards and Clinical Practice Guidelines in Cancer Care (updated w/ Lisbon Declaration)
� Psychosocial cancer care should be recognised as a universal human right;
� Quality cancer care must integrate the psychosocial domain into routine care;
� Distress should be measured as the 6th vital sign after temperature, blood pressure, pulse, respiratory rate and pain.
Endorsed by UICC and 75 cancer organizations worldwide
Clinical practice guidelines: NCCN Distress Thermometer & Problem List
National Comprehensive Cancer Network, 2015
• A cut-off point > 4 on
DT maximized
sensitivity (65%) and
specificity (70%) for
general psychosocial
morbidity;
• A cut-off >5 on DT
identified more severe
“caseness” (sensitivity=70;
specificity=73%)
NCCN DISTRESS THERMOMETER AND PROBLEM LIST : Treatment Guideline
Waiting room Oncology Office
Referral
Moderate - Severe distress
Mental Health
Social Work
Pastoral Counseling
Oncology Team
Mild distress
Brief screening for distress
and problem list
Assessment by Primary
Oncology Team
Referral
>5
<5
Use of the Distress Thermometer in Referral to psycho-oncological interventions
Steginga, Hutchison, Turner & Dunn, CancerForum. 2006 March; 30.
How to Assess& ManageDepression
Primary types of morbidity:
from physiological to pathological states
Normalsadness
Normalfears
Normal reaction
Subsyndromalsymptoms
Subsyndromalsymptoms
Subsyndromalsymptoms
Reactivedepression
Reactiveanxiety
Maladaptive coping
Clinicaldepression
Anxietydisorder
Adjustment disorders
Holland, 1998 (adapted)
Assessing Depression (loss)
differential diagnosis
� Persistent (weeks)
� Symptoms
� Depressed Mood
� Lost interest and pleasure
� Negative view of self, pastand present
� Worthlessness or guilt
� Hopelessness-helplessness
� Suicide thoughts (and/or plans)
Demoralization Clinical Depression
l Fluctuating over time
l Symptoms
– Sadness
– Passivity
– Negative view of future
– Irritability
– Respond to help
– If suicide thoughts
present non intense and
no plan
Symptoms of Depression
� Mood
� Depressed mood
� Loss of interest or pleasure
� Feelings of hopelessness
� Feelings of wothlessness
� Excessive or inappropriate guilt
� Cognitive symptoms
� Diminished ability to think or concentrate
� Memory impairment
� Recurrent thoughts of death and suicidal ideation
� Vegetative and somatic
symptoms
� Psychomotor retardation
� Anorexia and weight loss
� Sexual disorders (loss of libido)
� Fatigue or loss of energy
� Pain
� Other symptoms (gastrointestinal
disorders, headache, tension)
Assessing depression in cancer patients
When assessing depression in cancer patients evaluatewith caution somatic (vegetative) symptoms which couldbe caused by cancer or treatment rather than depressionitself (false positive):
� Low energy, fatigue
� Poor appetite or anorexia
� Weight loss
� Poor concentration
� Reduced libido
Depressive mood
Loss of interest
Worthlessness/
guiltSuicide
IdeationAgitation/
inhibition
Diagnosis of Major DepressionWorld Health Organization, WHO, ICD-10 1992
Sleep disturbanceDecreased appetite
Fatigue
Diminished ability
to concentrate
IPOS online curriculum
www.ipos-society.org
Assessment of Depressionin cancer
Questionnaire Authors Scales / Subscales Item
CES-D Center for Epidemiologic Studies
Depression Scale
CES-D 5 Center for Epidemiologic Studies
Depression Scale – 5 Item Version
Radloff 1977
Lewinsohn et al. 1997
Depression
Depression
20
5
MOS-D Medical Outcomes Study: MOS Rost et al. 1993 Depression 4
Questionnaire Authors Scales / Subscales Item
BDI Beck Depression Inventory, BDI-II
BDI-13 Beck Depression Inventory – SF
BDI-11 Beck Depression Inventory – SF
BDI-PC Beck Depression Inventory – PC
Beck et al. 1961, 1996
Beck et al. 1996
Steer et al. 2000
Beck et al. 1997
Depression 21
13
11
7
HADS Hospital Anxiety Depression Scale Zigmond & Snaith 1983 Subscale Depression 7
Zung Zung Self-Rating Depression Scale Zung 1965 Depression 20
PHQ Patient Health Questionnaire
PHQ-9 Patient Health Questionnaire 9
PHQ-2 Patient Health Questionnaire 2
Spitzer et al. 1999
Kroenke et al. 2001
Kroenke et al. 2003
Subscale Depression
Depression
Depression
9
2
BSI-53 Brief Symptom Inventory
BSI-18 Brief Symptom Inventory 18
Derogatis 1975, 1993
Derogatis & Spencer 1982
Derogatis 2000
Subscale Depression
Subscale Depression
6
6
IPOS online curriculum
www.ipos-society.org
HADS
Zigmond & Snaith 1983
Standard Treatment for Depression
• Psychosocial intervention (always)
Individual Psychological Treatment
Group Psychotherapy
• Psychopharmacological intervention (as needed)
Drugs with antidepressant properties (ADs)
Li, Fitzgerald & Rodin. Evidence-based Treatment of DEPRESSION in Cancer Patients. JCO 2012, 30: 1187-96.
How to Assess& ManageAnxiety
Anxiety is generated when someone interprets there is a threat to own integrity or that
of loved ones (e.g., disease, treatment procedures, surgery, chemo, etc.)
The primary symptoms are somatic symptoms:
• increased heart rate, shortness of breath,
• sweating, feelings of anxiety, dizziness,
• lightheadedness, paresthesia and nausea,
• problems concentrating, nervousness, and inner tension and irritableness.
Cognitive symptoms :
• fear of loss of control, fear of going crazy, fear of dying,
• feelings of irreality, catastrophic thoughts, and constant brooding
• “fear of recurrence”
Panic disorders (with or without agoraphobia), generalized anxiety disorders, and less
frequently phobic fears
Assessment of Anxiety symptoms and
Anxiety Disorders in cancer
Questionnaire Authors Scales / Subscales Item
HADS Hospital Anxiety Depression Scale Zigmond & Snaith 1983 Subscale Anxiety 7
SAS Zung Self-Rating Anxiety Scale Zung 1971 Anxiety 20
PHQ Patient Health Questionnaire Spitzer et al. 1999 Subscale Panic Disorder, Anxiety Symptoms
22
BSI-53 Brief Symptom Inventory
BSI-18 Brief Symptom Inventory 18
Derogatis 1975, 1993
Derogatis 2000
Subscale Anxiety
Subscale Anxiety
6
6
STAI State-Trait Anxiety Inventory Spielberger et al. 1970 State Anxiety
Trait Anxiety
20
20
SAI State Anxiety Index Sesti 2000 State Anxiety 20
FOP-Q Fear of Progression Questionnaire Dankert et a. 2003, Herschbach, 2003
Fear of Progression subscales
43
MAX-PC Memorial Anxiety Scale for Prostate Cancer
Roth et al. 2003 Prostate Cancer Anxiety
Fear of Progression
PSA Anxiety
11
4
3
Assessment of Anxiety and
Anxiety Disorders in cancer IPOS online curriculum
www.ipos-society.org
HADS
Zigmond & Snaith 1983
Traeger et al. Evidence-based Treatment of ANXIETY in Patients with Cancer. JCO 2012, 30: 1197-1205.
Mixed states:
depression and anxiety
� An estimated 60 to 80% of patients with clinical depression also have symptoms of anxiety and vice versa, anxiety disorders may complicate with depression
� Anxious depressed patients have more severe symptoms, reduced response to conventional therapy and poorer quality of life
difficult to have “pure” states,
since anxiety and depression often overlap
Psychological Intervention
� Cognitive-behavioral Intervention [Greer et al., BMJ, 1992]
� Supportive-Expressive Therapy [Classen et al., Arch Gen Psychiatry 2001]
� Cognitive-Existential Group Therapy [Kissane et al., Psycho-Oncology, 2003]
� Dignity Therapy [Chochinov et al, Lancet Oncol. 2011]
� Meaning-centered psychotherapy [Breitbart et al., JCO, 2015]
� CALM – Managing Cancer & Living Meaningfully [Rodin group, Pal
Med,2011, BMC 2015]
Conclusion:
MBSR shows a moderate to large positive effect size on the mental health
of breast cancer patients,further systematic investigation because it has a potential to make a significant
improvement on mental health for women in this group.
Fitch, Porter & Page, 2008 (adapted with permission)Canadian (CAPO) Guidelines
Psycho-oncology services provide effective (evidence-based, RCT’s) interventions for:
(a) preventing or reducing the distress and psychosocial morbidity associated w/ cancer
(b) improving patients’ skills to cope with the demands of treatment and the uncertainty of the disease
(c) improving their Quality of Life
(d) improving clinical outcomes
>> And are cost effective as well as general health costs reductive
Psychosocial Oncology Care is an important element of high-quality care
Integration of Psychosocial Oncology Care in Routine Oncology
IPOS - Luzia Travado
Conclusions
� Distress, Depression and Anxiety are frequent in cancer patients
� They have negative consequences on patients’ clinical outcomes
� Distress should be routinely screened and psychosocial needs
� psychosocial care routinely offered to all patients and referrals to
specialized care as needed
� Psychosocial Care Guidelines should be used to treat psychological
problems in a comprehensive way
� Multidisciplinary team with trained staff in psychosocial care to
address psychosocial needs
http://www.cancerworld.org http://www.ipos-society.org
IPOS Online Curriculum
Katalin Muszbek, M.D. Medical Director, Hungarian Hospice Foundation
Budapest, Hungary
Anxiety and Adjustment
Disorders in Cancer Patients
A Program in Psycho-Oncology, developed by the International Psycho-Oncology Society and the European School of Oncology
http://www.cancerworld.org http://www.ipos-society.org
Luigi Grassi, M.D. Section of Psychiatry, University of Ferrara, Ferrara, Italy
Yosuke Uchitomi, M.D., PhD
Psycho-Oncology Division, National Cancer Center Research Institute East, Kashiwa, Japan
Depression and Depressive Disorders in Cancer Patients
IPOS Online Curriculum
A Program in Psycho-Oncology, developed by the International Psycho-Oncology Society and the European School of Oncology
http://www.cancerworld.org http://www.ipos-society.org
Psychosocial Assessment in Cancer Patients
Anja Mehnert, PhD Uwe Koch, MD, PhD
Institute of Medical Psychology, University Medical Center Hamburg-Eppendorf
Hamburg, Germany
IPOS Online Curriculum
A Program in Psycho-Oncology, developed by the International Psycho-Oncology Society and the European School of Oncology
Luzia Travado
IPOS – ESO Online Curriculum
� Communication and Interpersonal Skills in Cancer Care by Walter Baile, MD (USA)
� Anxiety and Adjustment Disorders in Cancer Patients by Katalin Muszbek, MD (Hungary)
� Distress Management in Cancer Patients by Jimmie C. Holland, M.D, USA
� Depression and Depressive Disorders in Cancer Patients by Luigi Grassi, MD (Italy) and Yosuke Uchitomi, MD, P.D (Japan)
� Psychosocial Assessment in Cancer Patients by Uwe Koch, MD, PhD & Anja Mehnert, PhD (Germany)
� Cancer: A Family Affair by Lea Baider PhD (Israel)
� Loss, Grief and Bereavement by David Kissane MD (Australia)
� Palliative Care for the Psycho-Oncologist by William Breitbart MD (USA)
� Ethical Implications of Psycho-Oncology by Antonella Surbone MD, PhD, FAC (Italy)
� Psychosocial Interventions: Evidence and Methods for Supporting Cancer Patients by Maggie Watson PhD and Barry Bultz PhD (UK, Canada)
Multilingual Curriculum on Psychosocial Aspects of Cancer Care (English, French, German, Hungarian, Italian, Spanish, Portuguese, Chinese, Japanese)
www.ipos-society.org
Lisbon, Portugal
THANK YOU Luzia Travado, PhD
Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal
International Psycho-oncology Society
Luzia Travado, PhD
Head of Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal
International Psycho-oncology Society, President