1. Depressive Disorders in Oncology Luigi Grassi 1 and Michelle Riba 2 1 Professor and Chair of Psychiatry, University of Ferrara, Italy; Chair WPA Section on Psycho-Oncology and Palliative Care; Chair IPOS Federation Psycho-Oncology Societies; Past-President International Psycho-Oncology Society (IPOS) 2 Professor of Psychiatry, Associate Chair for Integrated Medicine and Psychiatric Services, Department of Psychiatry, University of Michigan, USA; Zonal Representative (Area 2, USA), World Psychiatric Association; Past President American Psychiatric Association; Chair WPA Section on Psychiatry in Medicine Copyright © 2011. World Psychiatric Association

2. Time Normal daily activities Adaptation Test Diagnosis Recurrence Active treatment Depression Depression in Cancer Palliative Care End of treatment Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.orgwww.ipos-society.org Copyright © 2011. World Psychiatric Association

3. Diagnostic Considerations Inclusive approach: all the symptoms (including somatic and vegetative symptoms) considered Substitute approach: somatic symptoms replaced with cognitive-affective items [Endicott, Cancer, 1984] Alternative approach: some new affective symptoms added to the original DSM criteria [Von Ammon Cavanaugh, Psychosomatics,1995] Exclusive approach: exclusion of somatic symptoms and use of only affective symptoms Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.orgwww.ipos-society.org Problems in clarifying the role of somatic symptoms (e.g., poor appetite, pain) that can be attributed both to depression or cancer Copyright © 2011. World Psychiatric Association

4. Demoralization Syndrome Affective symptoms of existential distress including hopelessness or loss of meaning and purpose in life Cognitive attitudes of pessimism, helplessness, a sense of being trapped, personal failure, or lacking a worthwhile future Absence of drive or motivation to cope differently Associated features of social alienation or isolation and lack of support Allowing for fluctuation in emotional intensity, these phenomena persist for more than 2 weeks A major depressive episode or other psychiatric disorder is not present as the primary condition Clarke DM, Kissane DW, Austr NZ J Psychiatry, 2002; Kissane et al., World Psychiatry, 2005 Copyright © 2011. World Psychiatric Association

5. Variables Associated With Depression Individual –Poverty –Younger age –Personal history (e.g. multiple losses previous psychopathological episodes) and personality traits –Tendency not to express emotions and to consider life events as uncontrollable and unavaoidable (external locus of control) Social –Concomitant stressful events –Poor social support Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.orgwww.ipos-society.org Copyright © 2011. World Psychiatric Association

6. Variables Associated With Depression (cont.) Biological –Type of cancer and site (e.g., lung, pancreas, gastrointestinal, head-neck, CNS) –Stage (metastatic vs local or loco-regional) –Phase (primary vs secondary or recurrence) –Physical symptoms (e.g., uncontrolled pain, nausea, vomiting, fatigue, low performance status and disability) –Metabolic (e.g., hypercalcemia, vitamin deficiency) or disease- related factors (e.g., cytokines, IL-6) –Treatment Chemotherapy (e.g., methotrexate, vincristine, vinblastine, asparaginase, procarbazine), anti-cancer drugs (e.g., interferon) or other drugs (e.g., corticosteroids) Hormone-therapy Adapted from Grassi L. & Uchitomi Y. (2005), Depression and Depressive Disorder in Cancer Patients. IPOS Core Curriculum in Psycho-Oncology, www.ipos-society.orgwww.ipos-society.org Copyright © 2011. World Psychiatric Association

7. Consequences of Depression in Cancer Maladaptive coping and abnormal illness behavior Poor Quality of Life Higher perception of pain Higher risk of suicide (and request for hastened death) Possible action in reducing the efficacy of chemotherapy Possible association with shorter survival time Reverberation on the family with risk of emotional disorders in family members Copyright © 2011. World Psychiatric Association

8. Management Considerations Communication Skills and Counselling Psychosocial Intervention –Adjuvant Psychological Therapy and Cognitive-Behavioral approaches –Supportive-Expressive Group Psychotherapy –Cogntive and Existential approaches –Interpersonal Psychotherapy –Other Mindfulness Cognitive Analytic Therapy Copyright © 2011. World Psychiatric Association

9. Management Considerations (cont.) Psychopharmacology –Selective Serotonin Reuptake Inhibitors - SSRIs (e.g., citalporam, escitalopram) 1 –Noradrenergic Reuptake Inhibitors - NARIs (e.g., reboxetine) 1 –Serotonin and Noraadrenergic Reuptake Inhibitors - SNARIs (e.g., duloxetine, venlafaxine) 1 –Dopamine and Noardrenergic Reuptake Inhibitors (e.g., bupropion) 1 –Noradrenergic and Specific Serotoninergic Antidepressants - NaSSAs (e.g., mirtazapine) 1 –Psychostimulants (e.g., low doses of dextroamphetamine, methylphenidate, pemoline, modafinil in terminally ill patients) 1 NB: Attention to the interaction between psychotropic drugs and anti-cancer agents! Copyright © 2011. World Psychiatric Association

10. Conclusions Depression is a common problem in people with cancer, ranging from demoralization as a syndrome to more severe forms of depression (e.g., major depression) Diagnostic problems (e.g., under-detection, reduced sensitivity/specificity criteria) should be solved The consequences of depression are remarkable both for the patient and their families Integrative treatment (psychosocial and psychopharmacological) should be available for depressed cancer patients More specific guidelines for depression are necessary in oncology settings Copyright © 2011. World Psychiatric Association