Dr.Richard Lim Boon Leong MBBS(UM), MRCP(UK) Consultant Palliative Medicine Physician Hospital Selayang Depression and anxiety are common psychiatric conditions in patients with advanced illness particularly cancer. In incurable cancer patients of 37 symptoms: Prevalence of depressed mood – 39% (9th) Prevalence of anxiety – 30% (15th) ▪ Constipation ranked 10th ▪ Dyspnoea ranked 16th Teunissen et al 2007 Prevalence of depression and anxiety in other non-cancerous conditions: Condition Cardiac failure End stage renal ds Depression 10-60% 19-52% Anxiety 11-45% 69-87% COPD 8-80% 6-74% WHO definition of palliative care: “…. prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Physical Psychological Total Pain Social Spiritual We are probably better at fixing the physical symptoms than psychological and spiritual Perception of physical symptoms are amplified by anxiety and depression leading to more suffering ANXIETY In palliative care, it is recognised that a having a terminal illness is indeed a frightening reality. Symptoms of fear and anxiety may occur for a variety of reasons. Tension Restlessness Jitteriness Autonomic hyperactivity Dyspnoea Numbness Nausea, abdominal discomfort Vigilance Insomnia Distractability Apprehension Worry Rumination Psychological Adjustment disorder Agitated depression Anxiety disorder Panic disorder Organic Delirium Hypoxia Sepsis Cardiac ds Poorly controlled pain Drug reactions Drug withdrawal Substance withdrawal Anxiety Subscale (0-7 / 8-10 / 11-21) 1. I feel tense or “wound up” 2. I get a sort of frightened feeling as if something awful is about to happen 3. Worrying thoughts go through my mind 4. I can sit at ease and feel relaxed 5. I get a sort of frightened feeling like 'butterflies' in the stomach 6. I feel restless as I have to be on the move 7. I get sudden feelings of panic Rule out and treat underlying organic causes (pain, respiratory distress, drug reactions etc) Pharmacological Benzodiazepines ▪ Mainstay of pharmaco mx of anxiety Neuroleptics (haloperidol , olanzepine) ▪ Delirium associated with anxiety Sedating antihistamines (hydroxyzine) ▪ Useful in patients with pain and anxiety Antidepressants (TCA , SSRI ▪ Anxiety assoc with depression Drug Dose range 10-60mg / day Route SC / IV Very short acting Midazolam Short acting Lorazepam Alprazolam Oxazepam 0.5-2mg tds/qid 0.25-2mg tds/qid 10-15mg qid PO/SL PO/SL PO Intermediate acting Diazepam 5-10mg bd-qid Clonazepam 0.5-2mg bd -qid PO PO Short acting benzodiazepines are the choice drug for anxiety in palliative care. Midazolam commonly used in crisis settings parenterally as continuous infusion and prn in terminal phase. Long acting useful in patients with seizure disorders and organic brain syndromes. Caution in liver impaired patients. DEPRESSION Depressed mood and sadness is common in patients with terminal illness and can often be deemed as an appropriate response. Major depression is reported to have a median prevalence of 15% in advanced cancer. (Hotopf et al 2002) Studies consistently report under-treatment and under-diagnosis of depression in palliative care settings. Challenge in palliative care is to differentiate depression from sadness. Classical DSM-IV criteria of somatic symptoms may be due to underlying organic problem: weight loss decreased appetite Insomnia/ hypersomnia fatigue diminished ability to concentrate Diagnosis is therefore more reliant on psychological or cognitive symptoms rather than somatic criteria. Anhedonia Feelings of worthlessness Hopelessness Excessive guilt Suicidal ideation 1. 2. 3. Inclusive approach Exclusive approach Substitutive approach Exclude the somatic criteria Endicott Substitution Criteria (somatic for other cognitive criteria) Clinician determines cause of physical symptoms. 7 instead of 5 Follow DSM-IV 4. 5. Aetiologic approach Higher threshold criteria DSM-IV Criteria Poor appetite or weight changes Loss of energy and fatigue or psychomotor retardation or agitation Insomnia and hypersomnia Endicott’s Substitution Tearfulness or depressed appearance Brooding, self-pity, pessimism Social withdrawal Feeling of worthlessness or Lack of reactivity, cannot be excessive guilt or diminished cheered up ability to think or concentrate Typical presentations: Persistent low mood, tearfulness and distress Loss of interest or pleasure in daily activities, social withdrawal Feelings of hopelessness, helplessness, worthlessness or guilt Suicidal thoughts, plans or actions, including requests for physician assisted suicide/ euthanasia Screening Tool Sensitivity Specificity Single-item “ Are you depressed?” Two-item “ During the last month, have you been bothered by feeling down, depressed or hopeless?” “During the last month, have you been bothered by having little interest or pleasure in doing things?” Hospital anxiety and depression scale (HADS) 0.42-0.86 0.74-0.92 0.91-1.00 0.57-0.86 0.68-0.92 0.65-0.90 If depression is suspected, a diagnostic interview should be performed. Clinician should further assess the details and context of patients symptoms. Understanding the social circumstances, past experiences, belief systems allows clearer interpretation of feelings to differentiate normal grief from depression. Depresion Feels outcast and alone Feeling of permanence Regretful, rumination on ‘irredeemable’ mistakes Extreme self-depreciation / self-loathing Constant and unremitting No hope/interest in future Enjoys few activities Suicidal thoughts/behaviour Sadness Able to feel intimately connected with others Feeling that some day this will end Able to enjoy happy memories Sense of self worth Comes in waves Looks forward to things Retains capacity for pleasure Will to live EPCRC guidelines on Mx of depression in palliative care 2011 Treatment modalities include: Optimal physical symptom management and psychosocial support Pharmacotherapy (TCA, SSRI, SNRI, NaSSA, psychostimulants) Supportive psychotherapy Cognitive behavioural interventions ▪ Relaxation and distraction ▪ Guided imagery Severity of depression Mild, moderate or severe Performance status of the patient Co-morbidities and concurrent symptoms Prognosis / Estimated survival MILD Characterised by a small number of symptoms with limited impact on the patient’s everyday life MODERATE Characterised by a larger number of symptoms which makes it difficult for the patient to function as they would normally SEVERE Characterised by a large number of symptoms which make it very difficult to carry out everyday activities. There may be psychotic symptoms, food and/or fluid refusal and persistent suicidal ideation EPCRC guidelines on Mx of depression in palliative care 2011 •Refer to Pall Care for symptom control and psychosocial support •Assess quality of relationships with significant others; facilitate communication • consider guided selfhelp programme •Consider brief psychological intervention (brief CBT, problem solving) MILD •Use recommendations as for mild depression •Initiate antidepressant meds and/or psychological therapy •Escalate dose or switch agent for persistent symptoms after 4 weeks MODERATE •Use recommendations as for mild and moderate depression • Consider hypnotic or sedative in sleep disturbed or very distressed patients •Refer to mental health specialist •Lithium, ECT, anti-psychotics SEVERE EPCRC guidelines on Mx of depression in palliative care 2011 Drug Usual daily dose range (mg) Tricyclic anti-depressants Amitriptyline 10-150 20-160 50-200 10-60 SSRI Fluoxetine Sertraline Citalopram SNRI Venlafaxine NaSSA Mirtazepine 75-225 15-60 Patients on TCA for neuropathic pain should consider increasing dose for depression rather than adding another agent if TCA is well tolerated. TCA should be avoided in cardiac failure, recent MI or conduction defects. Also avoid in prostatism, glaucoma and epilepsy Fluoxetine has active metabolite norfluoxetine with long halflife and may cause anxiety and appetite suppression. Not so useful in terminally ill. Sertraline and citalopram cause less induction of P450 isoenzymes and are safer in palliative care. Sertraline is SSRI of choice for recent cardiac events. Citalopram is safe in patients at risk of seizures Mirtazepine has specific benefits that may be useful in palliative care patients: May increase appetite May reduce nausea Has a sedative effect Early onset of action may be useful in short prognosis As most anti-depressants take up to several weeks for onset of response, patients with short life-expectancy and depression require an alternative approach to pharmacotherapy. Less than 3 weeks – consider psychostimulant Methylphenidate 2.5-15mg (at 8am and 12pm) Short days with terminal delirium and agitation Infusion with benzodiazepines and haloperidol Suicidal ideation is relatively infrequent in cancer patients and often only occurs in the significantly depressed patient. Allowing patients to discuss suicidal thoughts often decreases risk of suicide. Desire for hastened death increased 4-7x in depressed patients and associated with pessimistic cognitive style rather than symptoms of pain. Demoralization syndrome Hopelessness Loss of meaning Existential distress Distinct from depression Active listening Life review Group psychotherapy Dignity Conserving Care A – Attitude Healthcare providers examine their own attitudes and assumptions towards patient B-Behaviour Healthcare providers behaviour towards patient with kindness and respect in simple things. C- Compassion Compassion refers to a deep awareness of the suffering of another coupled with the wish to relieve it. D- Dialogue Dialogue must acknowledge personhood beyond the illness itself and recognise the emotional impact that accompanies illness Anxiety and depression are common symptoms in palliative care. These symptoms can amplify the perception of physical symptoms and increase suffering. Clinicians should understand the basic assessment and management of these conditions to provide holistic palliative care.
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