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L. Ubillos

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    ED 08 - Talking with Patients (ID 8)

    • Event: WCLC 2015
    • Type: Education Session
    • Track: Palliative and Supportive Care
    • Presentations: 1
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      ED08.03 - Depression, The Silent Killer (ID 1804)

      14:15 - 15:45  |  Author(s): L. Ubillos

      • Abstract
      • Presentation

      Background: Emotional reactions are natural and expected in individuals experiencing cancer and confronting the end of their lives, the differentiation between a normal and appropriate reaction to dying versus a psychiatric disorder such as major depression can be clinically difficult to differentiate. Depression is a common mental health problem in palliative cancer patients, unfortunately misunderstood, underdiagnosed, and undertreated. Depression is a major cause of suffering among patients with advanced disease or terminal illness like cancer. Depressive syndromes are correlated with a reduced quality of life, greater difficulty in managing the course of the patient's illness, decreased adherence to treatment, and earlier admission to inpatient or hospice care. It amplifies pain and other symptoms, and causes worry in family members and friends. Patients with advanced illness who suffer from depressive syndromes are also at high risk of suicide and suicidal ideation, and they have an increased desire for a hastened death. The recognition and diagnosis of patient depression, is often delayed in the course of the disease. Prevalence and risk factors: The reported prevalence of major depression in individuals with cancer varies from 3 to 38 percent. This wide variability is explained by the lack of agreement as to appropriate diagnostic criteria to be used in the setting of advanced illness, differences in patient populations, and variation in assessment methods. In general, rates are higher in populations with advanced cancer, greater levels of disability, and/or unrelieved pain. In several studies, younger cancer patients have higher rates of depressive disorders and self-reported distress. While depression is twice as common in women as compared to men in the general population, gender is not consistently reported to be a risk factor for depression in cancer patients. A prior history of depression is a risk factor for major depression in cancer patients. The presence of uncontrolled symptoms, particularly pain, is a major risk factor for depression and suicide among patients with cancer. The incidence of depression also depends upon the patient's particular illness. Among cancer patients, those with head and neck and pancreatic cancers are at a particularly high risk. Certain factors associated with the patient's illness or its treatment may be associated with depression. Central nervous tumors or metastasis to the central nervous system can cause depression. Other causes of depression in cancer patients include toxins created by the tumor, autoimmune reactions, and nutritional deficiencies. Depression can also represent an adverse effect from certain treatments, including glucocorticoids, chemotherapy drugs (vincristine, vinblastine, interferon and tamoxifen) as well as radiotherapy to the brain or head and neck. Patients who have high levels of spiritual well-being tend to be less depressed. The beneficial aspects of religion related primarily to spiritual well-being rather than to formal religious practice. Screening and diagnosis: Screening for depression should be carried out in all palliative care patients given the high prevalence of symptoms. Expert recommendations state that every patient with cancer should be screened for depression at initial diagnosis and thereafter as clinically indicated, especially with changes in cancer status or treatment. There are many tools to identify vulnerable patients by screening, Patient Health Questionnaire (PHQ-2) and PHQ-9 can identify deserving cases a deeper interview. Depressed mood, sadness, grief, and anticipatory feelings of loss are all appropriate responses to advanced disease and dying, however, feelings of hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are indicators of depressive syndromes in these patients. Although most used criteria for diagnosing major depression in non- oncology patients is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the most widely used for cancer patients is the substitutive approach of Endicott. This scale replaces four of the DSM-IV somatic criteria thought most likely attributable to medical illness or its treatment (ie, change of weight/appetite, sleep disturbance, loss of energy/fatigue, difficulty thinking or concentrating) with cognitive substitutes (depressed appearance, social withdrawal, brooding/self-pity/pessimism, and lack of reactivity in situations that would normally be pleasurable) Treatment: Unfortunately, some data suggest most cancer patients with depressive syndromes are undertreated. The first step in treating depression is to relieve uncontrolled symptoms, particularly pain and potentially reversible general medical cause of depressed mood. If depression persists once these are identified and controlled, specific therapy is warranted. Treatment should be tailored to the individual needs of the patient. In addition to drug therapy, effective psychosocial interventions include individual or group psychotherapy, cognitive-behavioral therapy, existential therapy, and self-help groups. There are no randomized trials that specifically address the benefit of psychotherapy for palliative care patients with depression. As a result, therapy for depression in these patients is generally based upon the larger evidence on effective treatments in patients of primary care populations with either no physical illness or less severe medical conditions. The agents used most commonly in palliative care patients are psychostimulants, selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs), these drugs are an important option for treatment of depression at the end of life because they take effect quicker than other classical drugs. Other advantages as their more favorable side effect profile and the markedly lower danger with overdose, led to the recomendation of the American College of Physicians in the 2008 clinical practice guidelines for initial treatment of depression in primary care patients, to initiate an SSRI, serotonin and norepinephrine reuptake inhibitors SNRI, or atypical antidepressant in this group of patients. Meyer HA. et al. Palliat Med 2003; 17:604 Portenoy LK. et al. Qual Life Res 1994; 3:183 Wilson KG. et al. J Pain Symptom Manage 2007; 33:118 Akechi T. et al. J Clin Oncol 2004; 22:1957 DeFlorio ML. et al. Depression 1995; 3:66 Endicott J. Cancer 1984; 53:2243 Andersen B. et al. J Clin Oncol 2014; 32:1605 Qaseem et al. Ann Intern Med. 2008;149(10):725

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