Anxiety and depression appropriate terms for cancer survivorship research?

Transcription

1 Anxiety and depression appropriate terms for cancer survivorship research? Jon Håvard Loge Regional Centre for Excellence in Palliative Care, Dept. of Oncol., Oslo University Hospital/ Dept. of Behavioural Sciences in Medicine, University of Oslo

2 Outline reflect on practice including own Terminology Prevalence of anxiety and depression Assessment methods HADS as is mostly used Distress Conclusions

3 Depression and anxiety Symptoms - continuous Syndromes categorical Psychiatric disorders diagnostic systems (ICD10 / DSMV) Depression Disorder (subtypes) Anxiety disorders: PTSD, GAD, PD Adjustment disorders Depression and anxiety symptoms co-occur Anxiety - common symptom among depressed (Brenne 2013) In adjustment disorders As emotional distress

4 Depression & anxiety prevalence ca. survivors Meta-analysis 2013 case control studies 16 studies on depression (N= vs ) 11.6% vs 10.2 Diversity of assessment methods HADS scored differently 4 used diagnostic criteria i.e. disorder 12 studies on anxiety (N= vs ) 17.9 vs 13.9 Anxiety disorders not specified Cut-offs on self-report instruments (HADS) Same phenomena studied? Mitchell AJ. LancOn 2013

5 Does terminology matter? Not distinguishing symptoms & syndromes Imprecise Health problems intermixed - grief vs. depression, temporary distress vs disorder Specific problems can be overlooked PTSD Limits clinical value of findings Planning, setting up services Informing our patients Selection for treatment Negative effect on our impact?

6 Depression

7 Depression symptom & disorder Most studied psychiatric problem in oncology > hits PubMed Anxiety: hits Prevalence estimates: 1-53% - explained by: Assessment method Sample characteristics Most commonly assessed by patients report on questionnaires > 100 instruments (Wasteson, 2009) I.e. studies of different depression symptoms not disorder

8 What is depression? Lowered mood melancholy (black gall) Term depression Assigned different meanings Psychiatrist vs. health professional vs. lay-man Categorical disorder vs. spectrum condition - discussed Categorical = a distinct entity different from other Spectrum = continuous phenomenon, i.e. mood in distress

9 DSMV-criteria depression disorder: symptom-threshold + duration + functional decline Criterion 1 Symptom type 1. Lowered mood 2 Psycological 2. Anhedonia 2 Psychological (?) 3. Anorexia / weight loss Somatic 4. Insomnia / hypersomnia Somatic 5. Psykomotor agitation / retardation Somatic 6. Fatigue Somatic 7. Selfblame Psychological 8. Lowered concentration Psychological 9. Thoughts dead / suicide Psychological 1 : Five or more present for more than 14 days and a change from previously 2 : One must be present

10 Assessment methods

11 Principle of psychiatric diagnostic systems - same symptom across severity levels Normal reactions emotions including: Irritability, anxiousness, lowered mood, sadness, grief.. Acute reactions: Strong normal reactions of short duration Adjustment disorders: More than anticipated i.e. > normal reactions Longer duration > 14 days Major Depressive Disorder Normal Pathological

12 Are we blinded by wording of the instruments? Hospital Anxiety and Depression Scale Beck s Depression Inventory CES-D (Centre Epidemiologic Studies Depression scale. Not taking face validity, construct validity & psychometric properties into account? Often more or less arbitrary cut-points Cheap & easy to administer Tradition?

13 Anhedonia a major depression criterion Anhedonia (+ mood + fatigue (ICD)) Inability to feel pleasure from stimuli that usually give pleasure 5 items on anhedonia in HADS (7 items anxiety and depression subscales) i.e. HADS-D is a measure of anhedonia Still enjoy things that used to enjoy Can laugh and see the funny side of things (+mood) Have lost interest in appearance Look forward with enjoyment to things (+mood) Can enjoy a book or radio or TV programme HADS: 2 other items Mood & retardation (=fatigue)

14 Anhedonia a valid depression criterion in (severely?) somatically ill? (BMT-sample N=116) EORTC item 24: Did you feel depressed

15 What can HADS be used for? HADS popular from 1980 s: Shortness, postulated robust towards disease (anhedonia) Not duration or functional consequences measure state Psychometrics - conflicting findings Factor structure inconsistent: 1,2,3 Best used as a unidimensional measure of distress? Depression disorder in palliative cancer patients HADS-D performed poorer than total sum-score and anxiety-score in detecting depression (Le Fevre 1999, LLoyd-Williams 2001) HADS not recommended for case-finding (Mitchell 2010) Total sum-score for distress screening

16 A «new» term - distress

17 NationalComprehensiveCancerNetwork Guidelines ( ) Chose the term distress because: Acceptable and not stigmatizing (i.e. political) Sounds normal (i.e. political) Can be defined and measured by self-report NCCN defined distress as: Distress is a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis. A wide definition Not followed by specific actions opposed to a diagnosis

18 Distress the original model

19 Distress used to screen for disorders! Reviews on instruments: Vodermaier A, J Natl Canc Inst 2009 Ability to accurately detect adjustment, depression and anxiety disorders Thekkumpurath P, J Pain Sympt Mange 2008 Ability to detect depression The concept also used more broadly, i.e. including delirium Of high relevance in itself - clinical encounters!

20 Conclusions Symptoms and disorders different constructs As in clinical practice Distress umbrella term launched for political reasons First generation self-report instruments still dominating Newer instruments available (PHQ-9 for depression), others for specific anxiety disorders Which disorders underlie the increased levels of anxiety? A common assessment and classification system? Based upon psychiatric diagnostic systems Reachable?

21 Thank you for your attention