Living Beyond Breast Cancer | - Assessing & … Dr...exists in all breast cancer patients Ethnic...

Assessing & Treating Depression

and Anxiety in Your Breast Cancer

Patients

Ruth H. Steinman, MD Clinical Assistant Professor

Department of Psychiatry

Perelman School of Medicine

University of Pennsylvania

Conflict of Interest Statement

There are no conflicts of interest to report.

Anxiety and Depression in Breast

Cancer Patients…

Are commonly experienced

There is an increased risk for depression

after breast cancer diagnosis (1)

Prevalence of clinical depression is 10-

30% within first 5 years after diagnosis (4)

Rate of depression is highest in first

weeks after diagnosis (5)

Why is this important?

Depression is common, often

preventable, treatable, and under-

recognized

Depression leads to profound suffering

for patients and their families

Depression can be deadly

Why is there increased mortality

with untreated depression?

Mortality is increased in breast cancer patients

who are depressed compared to those who are

not (9)

Depressed patients are less inclined to pursue

definitive treatment and adhere to cancer

treatment protocols

One review showed non-adherence is 3 times

greater among depressed cancer patients (12)

Depressed patients are at increased risk of

suicide

What is a Depressive Disorder?

Dysthymic Disorder

Major Depression

Adjustment Disorder with Depressed

Mood

Why is clinical depression missed?

There is a misconception that depression

exists in all breast cancer patients

Ethnic minority and low-income cancer

patients are at particular risk for missed

diagnosis and undertreatment of

depressive conditions (2)

Overlap of symptoms: appetite loss,

energy loss, cognitive slowing

Risk factors for clinical depression(1)

Prior history of MDD

Living alone/poor social support

Medical co-morbidity

Advanced disease

Limited education/low income

Pain/severity of physical symptoms

Functional disability

Other factors…

Cancer itself and chemotherapy cause

tissue destruction leading to increase in

pro-inflammatory immune cytokines (7)

Cancer disrupts neuroendocrine

processes (cortisol) and endocrine

effects of treatment can be culprits

Chemotherapy causes direct CNS

neurotoxicity

Clinical features of clinical depression (8)

Depressed mood

Decreased

pleasure/interest

Psychomotor

agitation/slowing

Excessive guilt/being

a burden

Negativity

Worthlessness

Emptiness

Irritability/anxiety

Functional

impairment

Cognitive slowing

Hopelessness

Helplessness

Suicidal ideation

Overlap symptoms

Overlap symptoms:

Fatigue/low energy

Low libido

Cognitive slowing/focus/memory

Insomnia

Low appetite/weight loss

Sadness and Suicidal Ideation are not

necessarily clinical depression

Sadness and depressed mood are

common in the breast cancer setting esp

around new dx, worsening prognosis,

cancer progression

Passive SI is common in cancer patients

and often represents fear about dying

and other concerns about the future

Both should alert clinicians to need for

monitoring and preventive interventions

Screening (10)

All breast cancer patients should be

screened for depressive symptoms at

the time of initial diagnosis and

periodically thereafter

Valid standardized screening tools

PHQ-2 (Table #1) 2 item questionnaire

PHQ-9 (Table #2) if answered greater or

equal to 3 in PHQ-2

Five areas to focus on

Depressed mood

Anhedonia (lack of pleasure)

Worthlessness or excessive guilt

Impaired decision making/cognition

Hopelessness/suicidal thinking

Active SI requires immediate attention

Severe symptoms including active suicidal

ideation with specific plan, intent and/or

behavior is an emergency and requires

immediate placement in an emergency

room for assessment

Pharmacologic Management of

Depression in Breast Cancer

Antidepressants are safe and effective

Particularly helpful at addressing

depressed mood, emotional lability,

irritability, and social withdrawal

Tamoxifen (15)

Antidepressants can interfere with the

conversion of the prodrug Tamoxifen to

its active metabolite

Venlafaxine does not affect this

conversion

Paroxetine (Paxil) and fluoxetine

(Prozac) are active inhibitors of this

process and should be avoided

SSRI

First line

Few sedative, anti-cholinergic or

autonomic SEs

Few drug interactions (except

Tamoxifen)

Initial serotonin-mediated nausea can be

helped with Zofran

Can relieve hot flashes

Mirtazapine

Sedating so can help with insomnia

Appetite and weight enhancing

Anti-nausea effect

Anti-anxiety effect felt sooner than with

SSRI/SNRI

SNRI

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

Tricyclic Antidepressants

All can help with neuropathic pain

All help with hot flashes

Stimulants

Potentiate analgesic effects of opioids

Counter-act sedating effects of opioids,

cancer treatments and other psychiatric

treatments

Paradoxically can increase appetite as

patient gains energy

Can act as antidepressant alone or in

combination with other antidepressants

Antidepressant Pearls

Avoid bupropion (Wellbutrin) in those

with high risk for seizures

Some antidepressants can increase the

blood levels of chemotherapy and other

medications so interactions should be

checked

Antidepressants can take 4-8 weeks to

begin to take effect

Non-pharmacologic management of

depression

Supportive/Meaning Centered Therapy

CBT (17)

Pastoral Care

Light Therapy

Yoga/meditation/relaxation/breathing

Factors which negatively affect coping

Extent of change in appearance

Spirituality

Developmental stage/level of maturity

Social support

Prior emotional trauma

Personality/resilience: Optimism-strong

predictor of emotional adjustment

Anxiety in breast cancer

Can be a normal response to

threat/uncertainty/loss of control

Can be increased at critical junctures in

cancer continuum (dx/tx/progression/end

of tx)

Can interfere with ability to receive

adequate cancer treatment

Can co-exists with clinical depression

What does anxiety look like?

Restlessness

Irritability

Shortness of breath

Ruminative worry

Insomnia/

Excessive fear

What is an Anxiety Disorder?

Generalized Anxiety Disorder

Adjustment Disorder with Anxiety

Post Traumatic Stress Disorder

Panic Disorder

Medical conditions can mimic anxiety

Meds:

phenothiazines/meto

clopramide/

Interferon/steroids

Pulmonary

emboli/hypoxia

Pain

Thyroid/adrenal

abnormality

Nutritional

deficiencies

(folate/B12)

CNS disorders

Sepsis

Withdrawal States

Anxiety Treatment: Medications

Antidepressants especially if co-morbid

depression or if Anxiety Disorder

Benzodiazepines for acute anxiety and

to augment anti-emetics

Antipsychotics: if resp depression a

concern; if benzo not effective; if

psychosis

Opiates/gabapentin for pain

Anxiety Treatment: Non-medication

Psycho-education

Acupuncture

Relaxation/yoga/meditation

Biofeedback

CBT

Supportive/expressive/family/couples/

group psychotherapy

Assess Coping Strategies (13)

Confrontative Coping

Distancing

Self-Control

Seeking Social

Support

Accepting

Responsibility

Escape-Avoidance

Planful Problem

Solving

Positive Re-

appraisal

Help with strategies for managing

uncertainty

Education

Find safe place to share fears and distress

Pace life to avoid being overwhelmed

Treat pain and other persistent treatment

related side effects to avoid demoralization

Set short term goals

Work on developing non-cancer identity

Friendship

Spirituality

More Strategies…

Reinforce past adaptive strategies for

coping under stress and uncertainty

Engage support from family, community,

health care providers: other’s optimism

can engender hope

Writing

Taking care of yourself can enhance

your sense of control

Diet/Nutrition

Exercise

Meditation/Mind-body interventions

Energy Therapies: Qi Gong; Reiki

Relaxation techniques

Breathing

Muscle relaxation

Guided imagery

What is Hope?

Belief that a positive outcome lies ahead.

We can learn to see that a positive

outcome can exist even if what we

originally hoped for is not likely to

happen.

Where Can I Find Professional

Help?

American Psychosocial Oncology

Society (APOS) Helpline:

1-866-APOS-4-HELP

www.apos-society.org/survivors/helpline

Living Beyond Breast Cancer

Resources

More information about all resources can be

found at LBBC.org

Breast Cancer Helpline 888-753-LBBC (5222)

Recorded Breast Cancer 360

Living Well After a Breast Cancer Diagnosis: Practical Tips

for Young Women

Guide to Understanding: Managing Stress and

Anxiety

Young Women’s Initiative Closed

Facebook Group

Table #1: PHQ-2

Patient Health Questionnaire-2 (PHQ-2)

Instructions: Please respond to each question.

Over the last 2 weeks, how often have you been bothered by any of the

following problems?

1. Little interest or pleasure in doing things

0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day

2. Feeling down, depressed, or hopeless

0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day

Developed by Drs. R.L. Spitzer, J.B. Williams, K. Kroenke and colleagues with an educational

grant from Pfizer, Inc. No permission required to reproduce, translate, display or distribute.

Table #2: PHQ-9

PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems?

Scoring: Not at all (0) Several days (1) More than half the days (2) Nearly every day(3)

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself, that you are a failure or have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so

fidgety or restless that you have been moving around a lot more than usual 0 1 2 3

9.Thoughts that you would be better off dead, or of hurting yourself 0 1 2 3

SCORE:

Developed by Drs, Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant

from Pfizer, Inc. No permission required to reproduce, translate, display or distribute.

Table #2: PHQ 9 scoring

PHQ-9 score

10 or over: Likely MDD

5-9: mild MDD

10-14: moderate MDD

15-19: moderately severe MDD

20 or over: severe MDD

Developed by Drs, Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an

educational grant from Pfizer, Inc. No permission required to reproduce, translate, display or

distribute.

Bibliography

1. Suppli NP, Johansen C, Christensen J, et al. Increased risk for depression after breast cancer: a nationwide population-based cohort study of associated factors in Demark, 1998-2011. J Clin Oncol 2014; 32:3831.

2. Ell K, Sanchez K, Vourlekis B, et al. Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol 2005; 23:3052.

3. Li M, Fitzgerald P, Rodin G. Evidence-based treatment of depression in patients with cancer. J Clin Oncol 2012;30:1187.

4. Mitchell AJ, Chan M, Bhatti H, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol 2011; 12:160.

5. Lu D, Andersso TM, Fall K, et al. Clinical Diagnosis of Mental Disorders Immediately Before and After Cancer Diagnosis: A Nationwide Matched Cohort Study in Sweden. JAMA Oncol 2016;2:1188.

6. Burgess C, Conrnelius V, Love S, et al. Depression and anxiety in women with early breast cancer: five-year observational cohort study. BMJ 2005; 330:702.

Bibliography Cont.

7. Torres MA, Pace TW, Liu T, et al. Predictors of depression in breast

cancer patients treated with radiation: role of prior chemotherapy and

nuclear factor kappa B. Cancer 2013; 119: 1951.

8. American Psychiatric Association. Diagnostic and Statistical Manual of

Mental Disorders, Fifth Edition (DSM-5), American Psychiatric

Association, Arlington 2013.

9. Pinquart M, Duberstein PR. Depression and cancer mortality: a meta-

analysis. Psychol Med 2010; 40:1797.

10. Thekkumpurath P, Walker J, Butcher I, et al. Screening for major

depression in cancer outpatients: the diagnostic accuracy of the 9-item

patient health questionnaire. Cancer 2011; 117-218.

11. Marmelstein H, Lesko L, Holland JC. Depression in the cancer patient. J

Psychooncology 1992; 1:199.

Bibliography cont.

12. Kissane DW. Unrecognised and untreated depression in cancer care. Lancet Psychiatry 2014; 1:320.

13. Folkman S, Lazarus, RS. Coping as a Mediator of Emotion. J of Personality and Social Psych; 1988;13.

14. Okamura M, Yamawaki, S, et al. Psychiatric Disorders following First Breast Cancer Recurrence: Prevalence, Associated Factors and Relationship to Quality of Life. Japanese Journal of Clinical Oncology. 2005;35(6):302-309.

15. Desmarais JE, Looper KJL Interactions between tamoxifen and antidepressants via cytochrome P450 2D6. J Clin Psychiatry. 2009; 70:1688-1697.

16. Wonghongkul T, Moore, SM, et al. The Influence of Uncertainty in Illness, Stress Appraisal, and Hope on Coping in Survivors of Breast Cancer. Cancer Nursing. 2000;23(6):422-429.

17. Nelson, JP. Struggling to Gain Meaning: Living with the Uncertainty of Breast Cancer. Advances in Nursing Science. 1996;18(3):59-76.

18. Stagl JM, Bouchard LC, Lechner SC, et al. Long-term psychological benefits of cognitive-behavioral stress management for women with breast cancer: 11-year follow-up of a randomized controlled trial. Cancer 2015; 121:1873.