Screening, assessment & management of …...Screening, assessment & management of Depression...

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