Depression and its consequences in cancer care Luigi Grassi

Transcription

1 Depression and its consequences in cancer care Luigi Grassi Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences University of Ferrara, Ferrara, Italy University Hospital Psychiatry Unit, Integrated Department of Mental Health & Addictive Behavior, University S.Anna Hospital and Health Authorities Ferrara, Italy

2 IPOS Online Core Curriculum

3 In this talk Depression and depressive spectrum disorders as severe medical and social diseases: the most important facts Depression in cancer Epidemiology and characteristics Consequences Diagnostic issues and treatment options

4 In this talk Depression and depressive spectrum disorders as severe medical and social diseases: the most important facts Depression in cancer Epidemiology and characteristics Consequences Diagnostic issues and treatment options

5 MDE=7-8% of the population million people -- Young Women: Men (2:1) suicide / year (1 / 40 seconds)

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7 The spectrum of depressive disorders Adjustment Disorders Demoralization Syndrome Grief Reactions

8 [Gold & Charney, Am J Psychiatry, 2002]

9 Depression and Disability World Health Survey: ~ 254,000 participants in 60 countries Moussavi et al., Lancet 2007

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11 In this talk Depression and depressive spectrum disorders as severe medical and social diseases: the most important facts Depression in cancer Epidemiology and characteristics Consequences Diagnostic issues and Treatment options

12 Psychosocial Morbidity in Cancer? 35-40%

13 Depression in Cancer

14 Major depression 5% to 16% 4% to 14% 4% to 11% 7% to 49%

15 Depression in Cancer 21,151 patients included in analysis HADS total score 15 + Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID)

16 Mean 11.5% Walker et al., 2014

17 Treatment received by pts w/ depression 73% 22% 5% Our most important finding à most cancer outpts. with MDE were not in receipt of potentially effective treatment for their depression. The under-treatment of patients attending specialist cancer services is especially concerning. Walker et al., 2014

18 Depressive Spectrum Disorders: Consequences Abnormal illness behaviour (AIB) [Grassi et al., 1989] Longer hospital stay and longer rehabilitation [Prieto et al., J Clin Oncol., 2002] Lower adherence [Colleoni et al., Lancet, 2000] Higher levels of pain [Spiegel et al., Cancer, 1994] Deterioration of QoL [Parker et al., Psycho-Oncology, 2003]

19 Depressive Spectrum Disorders: Consequences Burden for the family [Pitceathly & Maguire, Eur J Cancer, 2003] Lower efficacy of chemotherapy (when related to hopelessness) [Walker et al., Eur J Cancer, 1998] Shorter survival [Watson et al., Lancet, 1999; Prieto et al., JCO, 2005; Watson et al, 2005; Spiegel et al., JCO 2011] Risk of suicide [Robson et al., 2010]

20 Psychobiological consequences

21 Suicide in Cancer Patients Suicide ideation (SI) not uncommon in cancer patients (7-40%) in the different phases of illness need to be evaluated on regular basis [Spoletini et al., Crit Rev Oncol Hematol. 2011] Relationship of SI with à Depression, feeling a burden on the family, low social support, low levels of spirituality, pain [Breitbart et al JAMA 2000; 284: ; McClain et al Lancet : ] Risk of suicide is about 1.5 times higher in cancer patients than in the general population up to times in some types of cancer (e.g. pancreas, head and neck) [Hem et al., JCO, 2004; Robson et al., Psycho-Oncology, 2010; Smaylite et al., Cancer Nurs, 2013]

22 In this talk Depression and depressive spectrum disorders as severe medical and social diseases: the most important facts Depression in cancer Characteristics Consequences Diagnostic issues and treatment options

23 Screening, assessment and referral ESAS - PHQ9 BSI18 - HADS - Distress/Impact Thermometer

24 The importance of a correct approach 2 Key Questions - Depressed Mood - Anhedonia

25 Biopsychosocial risk factors for DSD in cancer Young age Personal or family history of DSD Personality traits (emotional repression; depressive personality) Poor coping mechanisms (hopelessness; life events as uncontrollable and unavoidable) DSD Type of cancer Stage / Phase Pain Fatigue Physical symptoms Treatment Life events Poor social support

26 Depressive Spectrum Disorders F32 Depressive episode (Major Depression) F33 Recurrent depressive disorder F34 Persistent mood [affective] disorders F41 Other Anxiety Disorders 41.2 Mixed anxiety and depressive disorder F43 Adjustment disorders F43.20 Brief depressive reaction F43.21 Prolonged depressive reaction F43.22 Mixed anxiety and depressive reaction

27 Spiritual Pain Demoralization Pain caused by extinction of the being and the meaning of the self" Three dimensions of the human being: a being founded on temporality, a being in relationship, and a being with autonomy. Loss of meaning and purposes in life Worthlessness of living derived from loss of the future Loss of identity, of autonomy of control about oneself Loss of dignity [Murata, Pall Support Care, 2003]

28 Demoralization Syndrome [de Figueiredo & Frank, 1982]

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30 Depression Care for People with Cancer (DCPC)/SMArT SMaRT à Symptom Management Research Trials Oncology

31 Depression Care for People with Cancer (DCPC)/SMArT 143 (62%) of 231 DCPC pts. vs. 40 (17%) of 231 UC pts. responded to treatment (odds ratio 8.5 p<0.0001). DCPC pts. vs. UC pts.: less depression, anxiety, pain, and fatigue; and better functioning, health, quality of life, at all time points (all p<0.05) DCPC more cost-effective than UC, providing new evidence regarding their use in specialist medical settings. Walker et al., Lancet Oncol 2014;; Duarte et al. J Psychosom Res, 2015

32 Primary Care

33 Cancer Health and Mental Health World Psychiatric Association

34 Take Home Messages Depression is a frequent concomitant in cancer It has remarkable negative consequences and should be routinely assessed and properly evaluated Necessary to view depression as a spectrum condition (with several risk factors to be evaluated) rather than a series of categorical disorders Guide-lines, programs and resources are necessary to early detect, properly refer and treat DSD through implementation of integrated psycho-oncology services and special interest programs within the mental health field