Depression and psychological distress - how are they related?

Transcription

1 h1 Depression and psychological distress - how are they related? JH Loge National Resource Centre for Long-term Studies after Cancer, Norwegian Radium Hospital & Dept. of Behavioral Sciences in Medicine, University of Oslo

2 Folie 1 h1 hloge;

3 Outline General issues Classification of psychological phenomena - a crash course Stress and distress Some general aspects Depression Use of the term in palliative care Distress In relation to cancer and palliative care Distress and depression In recent publications How is it modeled? Some viewpoints for discussion

4 How do you conceptualize? - each concept and the relation Distress Dep. Distress Dep. Distress Dep.

5 Distress and depression Complicated and often poorly defined terms Inconsistent use of both Distress Broad range of meanings Different subtypes Depression Narrower term 2 major meanings: An affect lowered mood (depressio mentis) a symptom A psychiatric disorder Major Depressive Disorder The relation varies: Depression included in the concept of distress Other psychiatric conditions also counted as distress

6 Principles of psych. classification Man-made not God-made (C. von Linné) Purpose of psychiatric classifications Communication between professionals Control i.e. select candidates who probably will benefit treatment Understanding quality control & research Most psych. symptoms occur in many conditions Also in normal reactions such as depr. mood in sadness Some central criteria for counting as disorders: Symptom load how much of each symptom - i.e. intensity Duration Functional consequences

7 Principles of psych. class. II DSM & ICD - non-hierarchical systems Jaspers 1913 created a hierarchical diagnostic system: organic / schizophrenia / mood disorder / personality disorder / neurosis The upper excluded the lower DSM & ICD - non-aetiological Based upon symptoms & behaviors Exception to non-aetiological: PTSD with a specific cause Psych. diagnosis = certain constellation of symptoms That is symptom clustering! The diagnoses = the clusters

8 Distress the concept Stress hard to define & hard to research As many perceptions as people? Never reached an agreed-upon definition In physics leading to strain old term Form of the Middle English destresse, derived via old French from the Latin stringere to draw tight (Wikepedia) H Selye 1930 s as a psychophysiological concept The reactions of the organism to external events Stressor = the perceived threat Renewed interest 1970 s life events & biological mechanisms Individualized response appraisal (Lazarus)

9 Distress the concept II Distress introduced by H Selye 1975 Persistent stress - not resolved through coping or adaptation May lead to anxiety or withdrawal (=depression) behavior Failure to deal with stress - i.e. a response to external events Opposed to eustress the good stress Different types of distress (Wikepedia) Fetal distress Respiratory distress Emotional distress Psychological distress Suffering...

10 Distress the original model

11 Depression Depression used as a term for: Depressed mood a symptom Loss of pleasure (anhedonia) a symptom A disorder of affect a syndrome as defined by the DSMIV / ICD-10 Partly a colloquial term feeling down, blue, What is measured by different assessment tools Depressed mood observed in different diagnoses Depressive episode Adjustment disorders Personality disorder (dystymia) Important to distinguish Depression as a disorder (the diagnosis of depression) from depression as a symptom In this context = the disorder

12 A disorder of affect: - DSMIV-criteria for depression Criteria 1 Type of symptom 1. Lowered mood 2 Psychological 2. Anhedonia * 2 Psychological (?) 3. Anorexia / weight loss Somatic 4. Insomnia / hypersomnia Somatic 5. Psychomotor agitation / retardation Psychological? 6. Fatigue Somatic 7. Feeling of guilt Psychological 8. Lowered concentration Somatic? 9. Recurrent thoughts of death / suicide Psychological 1 : 5 or more criteria present for last 14 days and a change from previous functioning 2 : Major criteria - one must be present *: Anhedonia = lacking ability to feel pleasure of stimuli that usually gives pleasure

13 Assessment of depression in pall.care - A systematic literature review 198 papers included 105 different assessment methods 64 used only once Usage not based upon definition of depression Traditional rather than quality reasons Regional differences, e.g. HADS most common in Europe while seldom employed in the USA or Canada Few studies classified depression Majority of classifications were cut-off scores (77%) Less than one third took duration into account 18% assessed consequences and impact upon functioning Depression: different phenomena across studies Depression = transient lowered mood = sadness =.. Wasteson L et al..subm 2009

14 Distress in pall./cancer care National Comprehensive Cancer Network guidelines Distress Management expert consensus Referring to emotional and psychological problems The term distress chosen for political reasons More acceptable / less stigmatizing than psycho Sounds normal and less embarrassing Can be defined and measured by self-report NCCN definition of distress in cancer:.. 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 fear to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis

15 Distress in pall./cancer care II - the Distress Thermometer How much distress during last week?

16 The Distress Thermometer II Additional content: Indicate problematic areas the past week (Yes / No) Practical problems (5 items) Family problems (2 items) Emotional problems (6 items) Spiritual / religious concerns Physical problems (21 items) Bodily functioning Mobility Different symptoms Anyone seen similar content in other contexts?

17 The Distress Thermometer III Published 1998 in relation to NCCN guidelines The benchmark for measuring the distress level of patients with cancer (JC Holland 2001) It is an assessment method comparison to others Validated for evaluation of distress And anxiety and depression Cut-off was 4v5 revised in 2007: 3v4 Rationale? Introduced as a screening tool Psychometric properties for psychiatric case detection: 50% Compared to other screening tools? Further developed into Emotion Thermometers (distress, anxiety, depression & anger)

18 Distress and depression NCCI guidelines (2008) - algorithm Brief screening tool risk score Assessment of risk factors Referral to Mental health, social or pastoral services Evaluation for Dementia Delirium Mood disorder - depression Adjustment disorder Anxiety disorder Substance-related or personality disorder Interpretation of conceptualization Depression = subcategory in distress Depression = a major cause of distress? NCCN Guidelines 2008,

19 Distress and depression II Measurement of psychological distress Different brief screening tools Incl. the distress thermometer More comprehensive screening tools Incl. HRQOL-instruments Different psychiatric disorders and assess. methods Disorders Depression Anxiety Delirium Interpretation of conceptualization Distress = poor (HR)QOL Depression = subcategory in distress Kelly B et al. Pall Med 2006; 20:

20 Distress and depression III Screening for psychological distress Points to a need for broader assessment Psychological problems in pall care do not fit traditional psychiatric classifications Adjustment disorders common an example Distress includes Psychological problems in pall. care Normal reactions Screening tools Unidimensional scales i.e. single items / distr. thermometer Multidimensional scales HADS, EDS.. Capacity for identifying depression correctly Interpretation of conceptualization Depression = subcategory in distress Distress does not include other psychiatric conditions Thekkumpurath P et al. J Pain Sympt Manage 2008

21 Distress and depression IV Clinical practice guidelines for the management of psychosocial distress at the end of life Expert opinions Adaptation of NCCN guidelines to end of life care Chosen distress to avoid stigma Distress along a continuum From normal reactions to depression, anxiety & delirium Interpretation of conceptualization Depression = subcategory in distress Depression = a major cause of distress? Murillo M, Holland JC, Pall Supp Care 2004; 2:

22 Distress: the assessment model Screening Screening Distress Psychiatric disorders - Depression, delirium, anxiety... Psychiatric disorders - Depression, delirium, anxiety... Traditional screening vs. NCCN guideline model Which model is optimal?

23 Distress & depression some comments Hospital Anxiety and depression Scale (HADS) Most commonly used tool for assessment of depression Also recommended as screening tool for distress! Does depression cause distress or Depression = extreme distress? Distress: another broad term Introduced for political reasons Alternative: Suffering good face validity Distress = poor HRQOL From content of the Distress thermometer Some challenges Does avoiding psycho reduce stigma? Does a new term influence practice an empirical question Does it help in identifying treatable disorders Clinical usefulness: State vs trait / treatable or self-limitating? Duration stability consequences Does screening improve care?

24 Do you conceptualize differently? Distress Dep. Distress Dep. Distress Dep.

25 Conclusions Distress A modern term from stress research Often assessed as HRQOL and depression NCCN Guidelines recommend unidimensional assessment Depression Assessed quite differently Very few studies use the diagnostic criteria Distress and depression Most authors: Depression: a subcategory of distress Cited commonly as underlying distress A cause of distress? Does distress cause depression? What improves care, treatment and research? A broad concept or focus on treatable disorders?