1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

2. EPEC  – Oncology Education in Palliative and End-of-life Care – Oncology Module 3h: Symptoms - Depression Module 3h: Symptoms - Depression

3. Depression... l Depressed mood l Anhedonia – loss of interest or pleasure l Lasting longer than 2 weeks l Depressed mood l Anhedonia – loss of interest or pleasure l Lasting longer than 2 weeks

4. ... Depression... l Irritability l Changes in: o Appetite or weight o Sleep o Psychomotor activity l Decreased energy l Worthlessness, helplessness, hopelessness l Guilt l Irritability l Changes in: o Appetite or weight o Sleep o Psychomotor activity l Decreased energy l Worthlessness, helplessness, hopelessness l Guilt

5. ... Depression l Difficulty thinking, concentrating, making decisions l Suicidal ideation or wishes to hasten death l Somatic symptoms often not helpful in this population l Difficulty thinking, concentrating, making decisions l Suicidal ideation or wishes to hasten death l Somatic symptoms often not helpful in this population

6. Risk factors... l Poorly controlled pain l Progressive physical impairment l Advanced disease l Medications o Steroids o Chemotherapeutics l Poorly controlled pain l Progressive physical impairment l Advanced disease l Medications o Steroids o Chemotherapeutics

7. ... Risk factors l Particular cancers o Pancreatic o Breast o Lung o Metastases to nervous system l Younger age l Presence of spiritual pain l Particular cancers o Pancreatic o Breast o Lung o Metastases to nervous system l Younger age l Presence of spiritual pain l Risk factors in general population: o Prior personal history o Family history o Presence of social stress o History of suicide attempts o substance use

8. Prevalence l Up to 58% of cancer patients

9. Prognosis l Untreated, associated with poor prognosis l Knowledge of true extent of disease and prognosis do not lead to depression or adverse outcomes l Untreated, associated with poor prognosis l Knowledge of true extent of disease and prognosis do not lead to depression or adverse outcomes

10. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

11. Pathophysiology l Involved neurotransmitters o Norepinephrine o Serotonin o Dopamine l Genetics l Environmental influences l Involved neurotransmitters o Norepinephrine o Serotonin o Dopamine l Genetics l Environmental influences

12. Assessment... l Assess for signs and symptoms noted mentioned previously l Family observations l Screening tools o Single question: “Do you feel depressed most of the time?” o Numerous other validated tools l Assess for signs and symptoms noted mentioned previously l Family observations l Screening tools o Single question: “Do you feel depressed most of the time?” o Numerous other validated tools

13. ... Assessment l Differentiate between: o Grief reactions o Adjustment disorders o Delirium, particularly hypoactive o Dementia l Consult with mental health professionals l Differentiate between: o Grief reactions o Adjustment disorders o Delirium, particularly hypoactive o Dementia l Consult with mental health professionals

14. Suicide l Suicidal thoughts are a sign of depression l Discussion may reduce the risk l Assess all depressed patients for risk  “Have you ever thought of committing suicide?”  “Do you have a plan?” l High risk if recurrent thoughts, plans l Suicidal thoughts are a sign of depression l Discussion may reduce the risk l Assess all depressed patients for risk  “Have you ever thought of committing suicide?”  “Do you have a plan?” l High risk if recurrent thoughts, plans

15. Management l Counseling l Complementary therapies l Pharmacotherapy l Combinations are best l Lack of improvement within weeks suggests more aggressive therapy or psychiatry consult needed l Counseling l Complementary therapies l Pharmacotherapy l Combinations are best l Lack of improvement within weeks suggests more aggressive therapy or psychiatry consult needed

16. Counseling l Weave into routine interventions  Include family when possible l Improve patient understanding l Create a different perspective l Identify strengths, coping strategies l Develop new coping strategies l Weave into routine interventions  Include family when possible l Improve patient understanding l Create a different perspective l Identify strengths, coping strategies l Develop new coping strategies

17. Complementary therapies l Relaxation l Distraction l Guided imagery l Meditation l Massage therapy l Relaxation l Distraction l Guided imagery l Meditation l Massage therapy l Aromatherapy l Self-hypnosis l Exercise l Sunlight

18. Pharmacotherapy... l Tricyclic antidepressants l Selective Serotonin Reuptake Inhibitors (SSRIs)  Preferred: less adverse effects l Psychostimulants l Other antidepressants l Tricyclic antidepressants l Selective Serotonin Reuptake Inhibitors (SSRIs)  Preferred: less adverse effects l Psychostimulants l Other antidepressants

19. ... Pharmacotherapy l Choose by time to effect:  Days: psychostimulants  Weeks to months: SSRIs, other antidepressants l Start dosing low, titrate slowly l Consider consultation l Choose by time to effect:  Days: psychostimulants  Weeks to months: SSRIs, other antidepressants l Start dosing low, titrate slowly l Consider consultation

20. Tricyclic antidepressants l Not first-line therapy when SSRIs available  Unless looking for Analgesic or sleep-altering effects l Latency 3–6 weeks l Adverse effects are common  Anticholinergic, cardiac  Nortriptyline, desipramine have fewer adverse effects l Not first-line therapy when SSRIs available  Unless looking for Analgesic or sleep-altering effects l Latency 3–6 weeks l Adverse effects are common  Anticholinergic, cardiac  Nortriptyline, desipramine have fewer adverse effects

21. SSRIs l Latency 2–4 weeks l Highly effective l Well tolerated l Once-daily dosing l Lower doses may be effective in advanced illness l Check for drug-drug interactions l Latency 2–4 weeks l Highly effective l Well tolerated l Once-daily dosing l Lower doses may be effective in advanced illness l Check for drug-drug interactions

22. Psychostimulants... l Rapid effect in hours to days l Minimal adverse effects l Alone or in combination with SSRIs l Can continue indefinitely l Tolerance may not be a factor l Diminish opioid-induced sedation l Rapid effect in hours to days l Minimal adverse effects l Alone or in combination with SSRIs l Can continue indefinitely l Tolerance may not be a factor l Diminish opioid-induced sedation

23. ... Psychostimulants l May exacerbate: o Tremulousness o Anxiety o Anorexia o Insomnia l May exacerbate: o Tremulousness o Anxiety o Anorexia o Insomnia l Choose: o Methylphenidate o Dextroamphetamine o Pemoline o Modafinil

24. Other antidepressants l May be particularly helpful for: o Sedation (mirtazapine, trazodone) o Energy (bupropion, venlafaxine) o Appetite stimulation (mirtazapine) l Still being studied in this population l May be particularly helpful for: o Sedation (mirtazapine, trazodone) o Energy (bupropion, venlafaxine) o Appetite stimulation (mirtazapine) l Still being studied in this population

25. Summary... l Very common l Intense suffering l Not inevitable l Treatable in most cases, with multiple approaches l Early treatment is better l Very common l Intense suffering l Not inevitable l Treatable in most cases, with multiple approaches l Early treatment is better

26. ... Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.