Chronology of Distress, Anxiety, and Depression in Older Cancer Patients International Workshop on Palliative Care to the Geriatric Oncology Patient Muscat, Sultanate of Oman, February 10-13, 2013 James C. Coyne, Ph.D. Department of Psychiatry, University of Pennsylvania Health Psychology Program, University of Groningen

Previously answered “of course,” but becoming controversial idea. Do older cancer patients experience fewer psychological symptoms- anxiety and depression? Previously answered “of course,” but becoming controversial idea. 2

Major depression 15% Anxiety disorders 10% Dysthymia 3%

Cancer is less disruptive of social roles such as parenting and employment Greater acceptance of mortality, inevitability of end-of-life Diagnosis and experience of cancer interpreted in the context of larger physical co-morbidities

Different themes for older cancer patients: Patients’ perception of effects on family members: family burden Lost opportunity to witness family transitions Widowhood and social isolation (important predictors of non-remission of clinical depression)

In general, major depression in the context of a general medical condition has longer episodes and a greater likelihood of relapse and recurrence. In the case of cancer, attention to depression is often sacrificed to the competing priority of dealing with the cancer, despite the reduction in morbidity that would be achieved by effective treatment of depression.

Depression among cancer patients is associated with:   Negative impact on patient’s quality of life Reduced acceptance of and compliance with treatment plans Prolonged hospitalizations Reduced effective coping Desire for early death or suicide

Trajectory of adaptation to a diagnosis of cancer and its treatment

Normal response to diagnosis of cancer is upset, sadness, fright, and worry about the future. It is difficult to immediately establish whether response is abnormal and when formal psychiatric diagnosis and treatment are appropriate. 10

Much of initial response to cancer diagnosis is self-limiting or responsive to attention and support and better information. By six months, residual distress tends to have existed before diagnosis, be tied to non-cancer factors, or reflect neuroticism or psychiatric comorbidity.

Different Patterns of Adjustment Never Distressed  52% of sample; No Elevations over time Resolved Distress  36% of sample; Elevated distress at diagnosis that resolves by 3 months Chronic Distress  12% of sample; Elevated distress at all times

Complex relationship within triad of depression, pain, and fatigue Mutually exacerbate Effective management of one may improve the other complaints

Deferred diagnosis of mild mental disorder, supportive action (stepped diagnosis, stepped care) 14

On the other hand, be alert to the early emergence of psychiatric disorder, particularly among patients with a past history Vegetative symptoms such as psychomotor retardation, extreme insomnia Pathological guilt and excessive self-blame

It is controversial whether cancer is associated with psychiatric co-morbidity more than with other physical health conditions. The challenge is making a diagnosis and ensuring adequate follow up within the competing demands of dealing with a life-threatening condition. 16

In general, major depression in the context of a general medical condition has longer episodes and a greater likelihood of relapse and recurrence. In the case of cancer, attention to depression is often sacrificed to the competing priority of dealing with the cancer, despite the reduction in morbidity that would be achieved by effective treatment of depression.

25 studies Antidepressants more efficacious than placebo at 4-5, 6-8, and 9-18 Superiority over placebo is apparent within 4-5 weeks and increases with continued use.

Detecting psychiatric morbidity: The argument against routine screening of cancer patients for depression and anxiety

Effective care for depression requires accurate diagnosis and follow up. Routine care for depression in general medical settings typically no better than receiving placebo in a clinical trial. Estimated that 40% of general medical patients receiving treatment for depression achieve no benefit over remaining on waiting list.

Rather than routinely screening patients for depression and placing them in inadequate routine care without follow-up: Concentrate on ensuring better follow-up care for known cases of depression Concentrate on patients at high risk for depression

Be aware of the limitations of common self-report screening instruments: Cut points may not hold in another language and culture unless cross validated Do not reliably distinguish between anxiety and depression symptoms Do not translate well (ex.- butterflies in the stomach)

The Hospital Anxiety and Depression Scale (HADS) should not be used Coyne JC, van Sonderen E: The Hospital Anxiety and Depression Scale (HADS) is dead, but like Elvis, there will still be citings. Journal of Psychosomatic Research. 73:77-78.

Importance of history psychiatric disorder

Psychiatric disorders tend to be recurrent and episodic, with onset the late teens or early 20s. Most psychiatric disorders in cancer patients will be recurrences, so past history a good predictor. Late onset depression is treatable, but less responsive than a recurrence.

Anhedonia Apathy Pain, fatigue masquerading as depressive symptoms

Many depressed patients do not renew prescriptions. About half require dosage adjustment, medication changes, or education about adherence at five weeks to achieve benefits.

Don't neglect needs of informal caregivers Don't neglect needs of informal caregivers. Initial symptomatology of women is higher than men, regardless of whether they are patients or spouses.

A key issue in the management of depression among elderly cancer patients is not the availability of efficacious treatments, but ensuring their effective delivery and follow-up.

Collaborative care for depression: At least 79 evaluations, 4 with the elderly, 3 with cancer patients Interdisciplinary team approach Key element is a depression care manager, usually a nurse Effect sizes in the range of => .30-.40

Is there an app for this? Challenge of collaborative care is sustainability, cost of care manager App decision aids for providers Cell phone support, reminders for patients

Thank you! jcoynester@gmail.com Follow me on Twitter @CoyneoftheRealm