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

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

3. Depression... l Depressed mood l Anhedonia – loss of interest or pleasure l > 2 weeks l Depressed mood l Anhedonia – loss of interest or pleasure l > 2 weeks

4. ... Depression... l Irritability l Changes in Appetite or weight Sleep Psychomotor activity l Decreased energy l Worthlessness, helplessness, hopelessness l Guilt l Irritability l Changes in Appetite or weight Sleep 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 SteroidsChemotherapeutics l Poorly controlled pain l Progressive physical impairment l Advanced disease l Medications SteroidsChemotherapeutics

7. ... Risk factors l Particular diseases Pancreatic, breast, lung, mets to nervous system l Younger age l Spiritual pain l Risk factors in general population Prior Hx, family Hx, social stress Suicide attempts, substance use l Particular diseases Pancreatic, breast, lung, mets to nervous system l Younger age l Spiritual pain l Risk factors in general population Prior Hx, family Hx, social stress Suicide attempts, 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 no lead to depression or adverse outcomes l Untreated, associated with poor prognosis l Knowledge of true extent of disease and prognosis do no lead to depression or adverse outcomes

10. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

11. Pathophysiology l Involved neurotransmitters NorepinephrineSerotoninDopamine l Genetics l Environmental influences l Involved neurotransmitters NorepinephrineSerotoninDopamine l Genetics l Environmental influences

12. Assessment... l Assess for signs and symptoms noted above Do you feel depressed most of the time? l Family observations l Screening tools l Assess for signs and symptoms noted above Do you feel depressed most of the time? l Family observations l Screening tools

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

17. Complementary therapies l Relaxation l Distraction l Guided imagery l Meditation l Massage therapy l Aromatherapy l Self-hypnosis 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 SSRIs Preferred as less adverse effects l Psychostimulants l Other antidepressants l Tricyclic antidepressants l SSRIs Preferred as less adverse effects l Psychostimulants l Other antidepressants

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

24. Other antidepressants l May be particularly helpful for: Sedation (mirtazapine, trazodone) Energy (bupropion, venlafaxine) Appetite stimulation (mirtazapine) l Still being studied in this population l May be particularly helpful for: Sedation (mirtazapine, trazodone) Energy (bupropion, venlafaxine) 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. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO... Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience