Module 11 - IPCRC.NET
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Transcript Module 11 - IPCRC.NET
The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
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EPEC – Oncology
Education in Palliative and End-of-life Care – Oncology
O
Module 3h
Symptoms –
Depression
Depression . . .
Depressed mood
Anhedonia – loss of interest or
pleasure
> 2 weeks
. . . Depression . . .
Irritability
Changes in
Appetite or weight
Sleep
Psychomotor activity
Decreased energy
Worthlessness, helplessness,
hopelessness
Guilt
. . . Depression
Difficulty thinking, concentrating,
making decisions
Suicidal ideation or wishes to hasten
death
Somatic symptoms often not helpful
in this population
Risk factors . . .
Poorly controlled pain
Progressive physical impairment
Advanced disease
Medications
Steroids
Chemotherapeutics
. . . Risk factors
Particular diseases
Pancreatic, breast, lung, mets to
nervous system
Younger age
Spiritual pain
Risk factors in general population
Prior Hx, family Hx, social stress
Suicide attempts, substance use
Prevalence
Up to 58 % of cancer patients
Prognosis
Untreated, associated with poor
prognosis
Knowledge of true extent of disease
and prognosis do no lead to
depression or adverse outcomes
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology
Involved neurotransmitters
Norepinephrine
Serotonin
Dopamine
Genetics
Environmental influences
Assessment . . .
Assess for signs and symptoms
noted above
Do you feel depressed most of the time?
Family observations
Screening tools
. . . Assessment
Differentiate between
Grief reactions
Adjustment disorders
Delirium, particularly hypoactive
Dementia
Consult with mental health
professionals
Suicide
Suicidal thoughts are a sign of
depression
Discussion may reduce the risk
Assess all depressed patients for risk
Have you ever thought of committing
suicide?
Do you have a plan?
High risk if recurrent thoughts, plans
Management
Counseling
Complementary therapies
Pharmacotherapy
Combinations are best
Lack of improvement within weeks
suggests more aggressive therapy or
psychiatry consult needed
Counseling
Weave into routine interventions
Include family when possible
Improve patient understanding
Create a different perspective
Identify strengths, coping strategies
New coping strategies
Complementary therapies
Relaxation
Exercise
Distraction
Sunlight
Guided imagery
Meditation
Massage therapy
Aromatherapy
Self-hypnosis
Pharmacotherapy . . .
Tricyclic antidepressants
SSRIs
Preferred as less adverse effects
Psychostimulants
Other antidepressants
. . . Pharmacotherapy
Choose by time to effect
Days – psychostimulants
Weeks / months – SSRIs, other
antidepressants
Start dosing low, titrate slowly
Consider consultation
Tricyclic antidepressants
Not first-line therapy when SSRIs
available, unless looking for
Analgesic or sleep altering effects
Latency 3 – 6 weeks
Adverse effects are common
Anticholinergic, cardiac
Nortriptyline, desipramine have fewer
adverse effects
SSRIs
Latency 2 – 4 weeks
Highly effective
Well tolerated
Once-daily dosing
Lower doses may be effective in
advanced illness
Check for drug-drug interactions
Psychostimulants . . .
Rapid effect in hours to days
Minimal adverse effects
Alone or in combination with SSRIs
Can continue indefinitely
Tolerance may not be a factor
Diminish opioid induced sedation
. . . Psychostimulants
May exacerbate
Choose
Tremulousness
Methylphenidate
Anxiety
Dextroamphetamine
Anorexia
Pemoline
Insomnia
Modafinil
Other antidepressants
May be particularly helpful for:
Sedation (mirtazapine, trazodone)
Energy (bupropion, venlafaxine)
Appetite stimulation (mirtazapine)
Still being studied in this population
Summary . . .
Very common
Intense suffering
Not inevitable
Treatable in most cases, with
multiple approaches
Early treatment is better
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. . . Summary
O
Use comprehensive
assessment and
pathophysiology-based therapy
to treat the cause and improve
the cancer experience