Transcript Depressive Disorders in Oncology

Depressive Disorders in
Oncology
Luigi Grassi 1 and Michelle Riba 2
1 Professor and Chair of Psychiatry, University of Ferrara, Italy; Chair WPA Section on Psycho-Oncology and Palliative Care; Chair IPOS
Federation Psycho-Oncology Societies; Past-President International Psycho-Oncology Society (IPOS)
2 Professor of Psychiatry, Associate Chair for Integrated Medicine and Psychiatric Services, Department of Psychiatry, University of
Michigan, USA; Zonal Representative (Area 2, USA), World Psychiatric Association; Past President American Psychiatric Association;
Chair WPA Section on Psychiatry in Medicine
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Depression in Cancer
Active
treatment
End of
treatment
Recurrence Palliative Care
Adaptation
Test
Diagnosis
Normal
daily
activities
Depression
Time
Copyright © 2011. World Psychiatric Association
Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder
in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.org
Diagnostic Considerations
Problems in clarifying the role of somatic symptoms (e.g., poor
appetite, pain) that can be attributed both to depression or cancer
• Inclusive approach: all the symptoms (including somatic
and vegetative symptoms) considered
• Substitute approach: somatic symptoms replaced with
cognitive-affective items [Endicott, Cancer, 1984]
• Alternative approach: some new affective symptoms
added to the original DSM criteria [Von Ammon
Cavanaugh, Psychosomatics,1995]
• Exclusive approach: exclusion of somatic symptoms and
use of only affective symptoms
Copyright © 2011. World Psychiatric Association
Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder
in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.org
Demoralization Syndrome
• Affective symptoms of existential distress including
hopelessness or loss of meaning and purpose in life
• Cognitive attitudes of pessimism, helplessness, a sense
of being trapped, personal failure, or lacking a worthwhile
future
• Absence of drive or motivation to cope differently
• Associated features of social alienation or isolation and
lack of support
• Allowing for fluctuation in emotional intensity, these
phenomena persist for more than 2 weeks
• A major depressive episode or other psychiatric disorder
is not present as the primary condition
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Clarke DM, Kissane DW, Austr NZ J Psychiatry, 2002; Kissane et al., World Psychiatry, 2005
Variables Associated With Depression
• Individual
– Poverty
– Younger age
– Personal history (e.g. multiple losses previous psychopathological
episodes) and personality traits
– Tendency not to express emotions and to consider life events as
uncontrollable and unavaoidable (external locus of control)
• Social
– Concomitant stressful events
– Poor social support
Copyright © 2011. World Psychiatric Association
Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder
in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.org
Variables Associated With Depression (cont.)
• Biological
– Type of cancer and site (e.g., lung, pancreas, gastrointestinal,
head-neck, CNS)
– Stage (metastatic vs local or loco-regional)
– Phase (primary vs secondary or recurrence)
– Physical symptoms (e.g., uncontrolled pain, nausea, vomiting,
fatigue, low performance status and disability)
– Metabolic (e.g., hypercalcemia, vitamin deficiency) or diseaserelated factors (e.g., cytokines, IL-6)
– Treatment
• Chemotherapy (e.g., methotrexate, vincristine, vinblastine,
asparaginase, procarbazine), anti-cancer drugs (e.g.,
interferon) or other drugs (e.g., corticosteroids)
• Hormone-therapy
Copyright © 2011. World Psychiatric Association
Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder
in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.org
Consequences of Depression in Cancer
•
•
•
•
•
•
•
Maladaptive coping and abnormal illness behavior
Poor Quality of Life
Higher perception of pain
Higher risk of suicide (and request for hastened death)
Possible action in reducing the efficacy of chemotherapy
Possible association with shorter survival time
Reverberation on the family with risk of emotional
disorders in family members
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Management Considerations
• Communication Skills and Counselling
• Psychosocial Intervention
– Adjuvant Psychological Therapy and Cognitive-Behavioral
approaches
– Supportive-Expressive Group Psychotherapy
– Cogntive and Existential approaches
– Interpersonal Psychotherapy
– Other
• Mindfulness
• Cognitive Analytic Therapy
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Management Considerations (cont.)
• Psychopharmacology
– Selective Serotonin Reuptake Inhibitors - SSRIs (e.g., citalporam,
escitalopram) 1
– Noradrenergic Reuptake Inhibitors - NARIs (e.g., reboxetine) 1
– Serotonin and Noraadrenergic Reuptake Inhibitors - SNARIs
(e.g., duloxetine, venlafaxine) 1
– Dopamine and Noardrenergic Reuptake Inhibitors (e.g.,
bupropion) 1
– Noradrenergic and Specific Serotoninergic Antidepressants NaSSAs (e.g., mirtazapine) 1
– Psychostimulants (e.g., low doses of dextroamphetamine,
methylphenidate, pemoline, modafinil in terminally ill patients)
1 NB: Attention to the interaction between psychotropic drugs and anti-cancer agents!
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Conclusions
• Depression is a common problem in people with cancer,
ranging from demoralization as a syndrome to more
severe forms of depression (e.g., major depression)
• Diagnostic problems (e.g., under-detection, reduced
sensitivity/specificity criteria) should be solved
• The consequences of depression are remarkable both for
the patient and their families
• Integrative treatment (psychosocial and
psychopharmacological) should be available for
depressed cancer patients
• More specific guidelines for depression are necessary in
oncology settings
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