Jane Fletcher Psychologist / Director Melbourne Psycho

Jane FletcherPsychologist / Director

Melbourne Psycho-oncology Service – Cabrini Health

Cabrini Monash Psycho-oncology Research Unit

Monash University

St Vincent’s Hospital Melbourne

Jane.Fletcher@med.monash.edu.au© Jane Fletcher 2009

Reactions to breast cancer

Vary from person to person

Problem Challenge

Life saving Devastating

Process of

Adaptation

Adjustment

Acceptance

Reactions to breast cancer

Adaptation, adjustment and acceptance

In own time

In own way

Unique experience

Depends on persons previous life challenges, coping and personality styles, social support etc

Issues after breast cancer

Physical issues

Social issues

Spiritual / existential issues

Health care / system issue

Emotional and psychological issues

Anger / resentment

Uncertainty

Loss of control

Hopelessness

Helplessness

Loneliness

Anxiety

Depression

What is depression? A deep persistent sadness and pessimism

Can affect anyone at any age

Extremely common

One in five (20%) people affected by depression at some time in their lives

One million Australian adults and 100,000 young people live with depression each year

More common in women than men

One in four females and one in six malesBeyond Blue, 2009

Edvard Munch, Despair, 1892

Edvard Munch, Despair, 1893-4

What is anxiety?

Feelings of persistent worry and fear

Some anxiety is good and motivates us to perform at our best

Excessive anxiety result in fight or flight reaction

‘Fighter’ ready for perceived aggression and unable to relax

‘Escaper’ (flight response) freezes with anxiety and may avoid upsetting situations or dissociate from the experience

Pedersen (2008)

Edvard Munch, Anxiety, 1894

Edvard Munch, Scream, 1893

Why is identifying and treating depression and anxiety important? Unmanaged depression and anxiety can result in

Significant reduction in quality life

Increased suicide risk

Treatment delays

Compliance issues

Increased complications

Increased health care costsAmerican Psychosocial Oncology Society (2006)

Depression and breast cancer

Depression and breast cancer Depression prevalent in 20-50% people with breast

cancer

At diagnosis – 20%-28%

Recurrent disease ~ 50%

Advanced disease – 20%-40%

Palliative care ~ 27%-77%

Depression can be associated with an increased desire for death and increased suicide rate

Population rates 5-20% - gender differences

(Breitbart et al 2000)

Depression and breast cancer Distinguish between ‘upset’ and clinically

significant distress

Periods of low mood and grief are ‘normal’ reactions to cancer

Level of ‘appropriate sadness’

Reaction is transient

Question depressive disorder when

Persistent

Impact on individual’s life and functioning

Types of depression

Major depression

Depressed mood > two weeks

Also called clinical depression or unipolar depression

Range of subtypes

Dysthymia

Less severe depressed mood that lasts for years

Types of depression

Mixed depression and anxiety

Combination of symptoms of depression and anxiety

Bipolar disorder

Periods depression and mania

Adjustment disorder

What causes depression? Biological - monoamine hypothesis

Deficiency of the neurotransmitters serotonin, norepinephrine and dopamine in the synaptic cleft between neurons in the brain

Psychological factors

Significant life events – breast cancer

Social

Familial predisposition

Unknown

Relationship between cancer and depression The relationship is complex

Depression after breast cancer may be triggered by

Diagnosis

Other issues related to the breast cancer and its treatment

Impact of the cancer person's life

May be related to other difficult life events (past or present)

Who is most likely to develop depression?

Pre morbid depression

Socially isolated

Other significant life events

Co-morbidities

Drug interactions and side effects

Steroids

Opioids

Benzodiazepines

Who is most likely to develop depression?

Significant cause of depression in cancer patients

Depression may change perceptions of the meaning and severity of pain

Pain or fear of unrelieved pain critical variable in requests of physician assisted suicide

Diagnosing depression?

DSM – IV TR Criteria: Major Depressive Episode

Depressed mood

Diminished interest or pleasure in activities

Significant weight loss/gain or decrease/increase in appetite

Insomnia or hypersomnia

Diagnosing depression?

DSM – IV TR Criteria: Major Depressive Episode

Fatigue or loss of energy

Feelings of worthlessness or excessive guilt

Diminished ability to think or concentrate or indecisiveness

Recurrent thoughts of death or suicidal ideation

Criteria for major depression One or both of main emotional symptoms of

depression

Dysphoria (sadness)

Anhedonia (lack of pleasure)

Plus at least five of the somatic symptoms

DSM-IV TR criteria also require

Presence of vegetative and/or somatic symptoms with psychological symptoms and must be present for two weeks and present a significant change from prior functioning

Psychological symptoms of depression

Dysphoria (sadness)

Anhedonia (lack of pleasure)

Hopelessness

Feelings of guilt

Worthlessness

DEPRESSION

Alteration in mood (anxiety/depression)

Fatigue

Low energy

Loss of appetite

Loss of sleep

Psychomotor retardation

CANCER AND ITS TREATMENT

Pain and other symptoms

Fatigue

Low energy

Loss of appetite

Loss of sleep

Psychomotor retardation

Vegetative and somatic symptoms

Mnemonic for depression diagnostic criteria SIGECAPS

Sleep (increase/decrease)

Interest (diminished)

Guilt/low self esteem

Energy (poor/low)

Concentration (poor)

Appetite (increased/decreased)

Psychomotor (agitation/retardation)

Suicidal ideation

Major depression

Depressed mood for 2 or more weeks plus 4 SIGECAPS

Dysthymia

Depressed mood, plus three SIGECAPS for 2 years, most days

Unipolar - not bipolar disorder with depressed mood

If patient who is prescribed antidepressants begin to show manic symptoms may be bipolar

Be alert to reports that patients are:

Having a very low mood for most of the time

Not being able to be lifted out of low mood

Not feeling usual self

Not being able to enjoy anything

Loss of interest in favourite activities

Feeling worse in the mornings

Problems getting off to sleep or waking early

Poor sleeping patterns or sleeplessness

Poor concentration and forgetfulness

Feelings of guilt/burden/blame

Feeling helpless or hopeless

Feeling vulnerable or oversensitive

Feeling close to tears

Irritability

Loss of motivation, unable to start or complete jobs

Physical hyperactivity or inactivity

Loss of interest in sex

Thoughts of suicide or death

Slow speech; slow movements

Drug or alcohol abuse

Adjustment disorders

Often called minor depression or reactive depression

Abnormal and excessive reaction to a life stress

Most common mood disorder in cancer patients

Symptoms typically begin within 3 months of the stressor, and do not last longer than 6 months after stressor stops

Ongoing stressors-breast cancer?

Diagnostic criteria

The symptoms clearly follow stressor

The symptoms are more severe than would be expected

There do not appear to be other underlying disorders

Diagnosis requires

Sadness or inability to find pleasure in life as a response to stressor like cancer

Temporally related to onset of symptoms

Symptoms sufficiently severe to cause impairment in social and occupational functioning

Treatment for depression

If patient depressed refer them to the appropriate health professional/s

Psychologist

Psychiatrist

Social worker

Counsellor

Treatment for depression Pharmacological

Antidepressants

Psychological

Psychotherapy /psychotherapeutic interventions

Lifestyle factors

Exercise

Pharmacological – antidepressants Prescribed medical doctor

Best when combined with psychological / psychotherapeutic interventions

Use for major depression or when symptoms are severe - patient dependent

Mechanisms differ depending of class

Norepinephrine

Serotonin

Pharmacological – antidepressants

Between 2-4 weeks to take effect

Monitor side effects and symptom response

Pharmacological – antidepressants

Side effects are usually mild and resolve within first few weeks

Dry mouth

Drowsiness

Nausea

Sleeplessness

Sexual problems

Headaches

Pharmacological – antidepressantsClasses commonly used in cancer patients

Tricyclic antidepressants (TCAs)

More side-effects than newer drugs

Monoamine oxidase inhibitors (MAOIs)

Difficult to use due to drug-drug and drug-food interactions

Selective serotonin reuptake inhibitors (SSRIs) eg Sertraline – Zoloft, Fluoxetine – Prozac/Lovan

Highly effective

Reduced side effect profile

Generally non sedating

Serotonin and noradrenaline reuptake inhibitors (SNRIs) eg Venlafaxine – Effexor

Fewer side effects

Effective in severe depression

May assist with hot flushes and neuropathic pain

Noradrenaline-serotonin specific antidepressants (NaSSAs) eg Mirtazapine– Remeron

Relatively new antidepressants

Particularly helpful when there are problems with anxiety or sleep

Generally low in sexual side-effects

Psychological interventions

Provided by

Psychologist

Psychiatrist

Social Worker

Counsellors / Psychotherapist

Some GPs

Check qualifications and experience in dealing with cancer patients

Types of therapies include

Cognitive Behavioural Therapy (CBT)

Supportive or existential psychotherapy

Acceptance and Commitment Therapy (ACT)

Therapy is usually individualised and will differ for each person

Many therapists will use a range of techniques

Cognitive Behavioural Therapy

Present based

Teaches problem solving

Reframing attitudes

Challenges ‘black and white thinking’

Relaxation skills

Guided imagery

Encourages expression of emotion

Validates individual experience

Support through empathic listening and encouragement

Utilises information provision

Highlights strengths of individual

Encourages use of adaptive coping

Psychological interventions Acceptance and Commitment Therapy

Acceptance of what is out of your personal control, while committing to do whatever is in your personal control

Teaches psychological skills to deal with painful thoughts and feelings effectively – mindfulness skills

Helps to clarify what is truly important and meaningful i.e. values - then use that knowledge to guide, inspire and motivate person to change life for the better

Lifestyle factors

Exercise

Evidence exercise improves mood

Getting enough sleep

Good sleep hygiene

Natural therapies

St John’s Wort

Anxiety and breast cancer

Anxiety ~ 35% of patients with cancer diagnosis

Range of disorders with different rates(Zabora et al, 2000)

Anxiety and breast cancer? Feelings of anxiety increase or decrease at different

Most patients are able to reduce their anxiety by learning more about their cancer

For some, particularly those who have experienced episodes of intense anxiety before their cancer diagnosis, feelings of anxiety may become overwhelming

Most patients who have not had an anxiety condition before their cancer diagnosis will not develop an anxiety disorder associated with cancer

Anxiety and breast cancer Some level of anxiety is a normal reaction to breast

cancer

Difficult to distinguish between normal fears associated with cancer and abnormally severe fears that can be classified as an anxiety disorder

Anxiety associated with cancer may increase

Feelings of pain

Interfere with sleep

Nausea and vomiting

Reduce quality of life

What is anxiety?

Primary psychiatric disorders

Generalized anxiety disorder (GAD)

Pervasive feeling of dread or apprehension

Panic disorder +/- agoraphobia (avoidance of places that may result in panic)

Obsessive-compulsive disorder

Post traumatic stress disorder

What is anxiety?Cancer related anxiety

Psychological anxiety can be interpreted as a reaction to a threat

Anxiety increases in certain situations

Initial diagnosis

Treatment

Lead up to follow up appointments

Waiting for test results

Recurrence

What is anxiety?Phobic reactions

Anxiety that may lead to full blown panic

Claustrophobic patients and MRI/CT scans

Needle phobia

White coat syndrome

What is anxiety?Conditioned response

Anticipatory nausea

Often associated with anxiety

Survivors

Undergo additional treatment

Anxiety related to breast cancer Some persons may have already experienced

intense anxiety in their life because of situations unrelated to their cancer

These anxiety conditions may recur or become aggravated by the stress of a cancer diagnosis

Patients may experience extreme fear, be unable to absorb information given to them by health professionals, or be unable to follow through with treatment

Signs and symptoms of anxiety

Psychological

Worry, apprehension, fear and sadness

Patients may be able identify focus or source of these symptoms

Often non-specific and ‘free floating’

Crying spells, ruminations

Inability to ‘turn off’ – especially at night

Physical

Tachycardia and tachypnea

Tremor

Diaphoresis

Nausea

Dry mouth

Insomnia

Anorexia

Signs and symptoms of anxiety May be intermittent – increasing over hours or days

Occurs in response to stressor - anticipation of upcoming diagnostic test and passes once stressor over

May be persistent and pervasive through day

Typical of primary anxiety disorders

Co-morbid depressive symptoms

Reactions to chronic stressors (eg fear of recurrence, family and financial problems)

Side effects of regular medication

Panic attacks present with acute anxiety

Severe palpitations, perspiration and nausea

Great fear of catastrophic event

Feeling of impending doom

Usually last for several minutes

Multiple events can occur in one day

Be alert to reports that patients are: Feeling shaky, jittery, or nervous

Tense, fearful, or apprehensive

Having to avoid certain places or activities because of fear

Palpitations

Trouble catching breath when nervous

Unjustified sweating or trembling

Knot in stomach

Lump in throat

Be alert to reports that patients are: Pacing

Afraid to close eyes at night for fear that may die in sleep

Worry about the next diagnostic test, or the results of it, weeks in advance

Sudden fear of losing control or going crazy

Sudden fear of dying

Intense worry about pain or other physical issues

Confusion or disorientation

Who is most likely to develop anxiety disorder? History of anxiety disorders

Experiencing anxiety at the time of diagnosis

Severe pain

Socially isolated

Non responsive cancer

History of severe physical or emotional trauma

Cancer medications and treatments

Treatment for anxiety disorders

If patient anxious refer them to the appropriate health professional/s

Psychologist

Psychiatrist

Social worker

Counsellor

Types of treatment for anxiety disorder

Depends on how the anxiety is affecting daily life

Treat the cause of anxiety if possible

Pain or another medical condition

Medication side effect

All treatment begins with adequate information and support

Medications may be used alone or in combination with psychological therapies or strategies

Treatment for anxiety disorder Pharmacological

Anti-anxiety

Antidepressants

Psychological

Psychotherapy /psychotherapeutic interventions

Lifestyle factors

Exercise

Pharmacological therapies

Anti-anxiety medication

Benzodiazepine

Short acting such as lorazepam (Ativan) and alprazolam (Xanax)

Rapid action

Useful for intermittent acute anxiety or panic

Pre meds

Preferred in seriously ill

Benzodiazepine

Longer acting such as diazepam (Valium) and clonazepam (Klonopin)

Useful for more persistent anxiety

Less tolerance

Fear of addiction vs. symptom control

Antipsychotic drugs

Haloperidol (Haldol)

Use in low doses for anxiety

Especially if agitation and tremor present

Opioid analgesics

Morphine

Effective in terminally ill

Antidepressants

Patients with pre existing anxiety

No used on an ‘as needed’ basis

Psychological interventions Types of psychological therapies include

Psycho-education

Active problem solving

Cognitive Behavioural Therapy (CBT)

Acceptance and Commitment Therapy (ACT)

Mindfulness Based Stress Reduction (MBSR) techniques

What else is helpful?

Helpful psychological strategies

Expressive therapies

Journaling

Self-help groups

Peer support

Stress reduction techniques

Mindfulness based stress reduction - meditation

Relaxation techniques

Guided imagery

Biofeedback

Hypnosis

Mindfulness exercise

Tai Chi

Qigong

Relaxation techniques

1 – 10

Deep breaths

Relax, relax, relax………………

Metronome / clock

Progressive muscle relaxation

Mindful focus on the breath

Special place

Screening for distress

Early detection

Early assessment / referral

Early treatment / intervention

Early detection = screening on a routine basis

Embedded in routine care at multiple time intervals

Distress Thermometer

0–10 visual analogue scale - indicate level of distress on the scale

"No Distress" at 0

"Moderate Distress" at the midpoint

"Extreme Distress" at 10

Supplementary questions covering various areas of distress (e.g. family problems, physical problems)

Distress Thermometer

Cut off for referral generally 4

Referral to appropriate source given results of problem list

Re screen on a regular basis

Evaluate outcome of intervention and referral

Other measures to screen for distress

10 items measuring anxiety and depression symptoms

Used by GPs as part of MHCP assessment

Scores 20 or above indicative of disorder and need referral for assessment and treatment

Simple questions to assess mood Three questions used in primary care to detect

depression

During the past month, have you been bothered by feeling down, depressed, or hopeless?

During the past month, have you been bothered by little interest or pleasure in doing things?

Is this something with which you would like help?

Arroll et al 2005

Simple questions to assess mood Other questions that may be useful

‘Anxiety is understandably common in people who have been treated for cancer. Would you say that anxiety is an issue for you?’

‘Coping with cancer isn’t just about physical issues, the emotional impact is important too.’‘Could you tell me what the cancer has meant emotionally?’‘Would say that you have ever felt really sad or depressed?’

NBOCC & NCCI, 2003

Cancer Helpline 13 11 20 Speak to GP or health professional

Medicare rebateable psychological assistance under the Better Outcomes in Mental Health Care program is available – discuss with GP

Those who need help are not alone

Jane Fletcher Psychologist / Director Melbourne Psycho

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