1. 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

2. 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

3. Major depression 15% Anxiety disorders 10% Dysthymia 3%

5. 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

6. 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)

7. 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.

8. 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

9. Trajectory of adaptation to a diagnosis of cancer and its treatment

10. 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

11. 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.

12. 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

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

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

15. 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

16. 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

17. 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.

18. 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.

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

20. 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.

21. 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

22. 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)

23. 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.

25. Importance of history psychiatric disorder

26. 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.

27. Anhedonia
Apathy
Pain, fatigue masquerading
as depressive symptoms

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

29. 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.

30. 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.

31. 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 =>

32. 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

33. Thank you!
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@CoyneoftheRealm