1. Anxiety and Depression in Paediatric Palliative Care Dr Emma Heckford July 17 th 2012 Disclaimer: Whilst every effort has been made to ensure that the information in this presentation is accurate and referenced the author does not accept any responsibility for the use by any third parties.

2. Aims  Be able to think about and distinguish Be able to think about and distinguish between anxiety, depression and delirium Put into palliative care context Evidence based approaches to assessment and management

3. The Challenges Little research re psychological symptoms in PPC Few assessment tools developed for children Most of what we know about treatment comes from adult practice

4. Best practice Truly holistic care Ideally psychology input integral to palliative care team Involve psychiatry services when needed Drugs rarely the only (or best) answer

5. Depression Barriers to adequate assessment: – Limited assessment tools – ‘Normal in the circumstances’ – not a valid excuse – Reluctance to address as out of comfort zone Risk factors: – Pre-existing psychosocial factors – Maternal psychological/psychiatric state

6. Management of Depression (1) General principles: – Open communication, sensitive listening and honesty – Taking time – Regular review – Careful history – Learn about the family, their stresses and their coping mechanisms

7. Management of Depression (2) NICE Guidance 2005 – Depression in Children – Open and honest discussion (prevention) – Ideally assessment by a psychiatrist – Psychological therapies first line – Ideally, meds only alongside psychological therapies – Fluoxetine first line (evidence based) – No studies on use of antidepressants in PPC – Plausible that complementary therapies/ relaxation techniques may help

8. Management of Depression (3) Fluoxetine – Evidence that benefits outweigh harms (Emslie et al 2002) – Start 10mg and increase to 20mg daily after 1 week if necessary – Onset of action – 4-6 weeks – need to warn children and families – Need careful monitoring (for suicidal behaviour, self-harm) when first started - weekly clinical contact suggested – Other SSRIs only if intolerant of fluoxetine TCAs and St John’s Wort shown not to be effective NB: 1.NICE guidance applies 12 – 18 yrs, below this very little evidence 2.All antidepressants in children are unlicensed

9. Anxiety Similar principles to depression: – Consider it – Take time to communicate sensitively and find out more – Not enough to say ‘normal in the circumstances’ – Similar risk factors – Tools not very helpful

10. Management of Anxiety (1) Communication key – Listening – Finding out what they know – Finding out what they are worried about – Being honest – Reassuring where possible – Children who understand about their condition are less anxious

11. Management of Anxiety (2) Explore all ways of expression: – Art therapy, music therapy, play therapy…. And all methods of relaxation: – Massage, hypnosis…..

12. Management of anxiety (3) Short-term – Benzos Longer term – Fluoxetine first line Guidance re fluoxetine for anxiety same as for depression (NICE 2005): – Ideally assessment by a psychiatrist – Psychological therapies first line – Ideally, fluoxetine only alongside psychological therapies

13. Delirium = acute confusional state Sometimes seen terminally Altered perception, disorientation, hallucinations May fluctuate Can be difficult to know in those with cognitive delay

14. Causes of delirium Many: – Drugs (steroids, opioids) – Drug withdrawal – Cerebral disease hypoxia, infection, stroke, tumour – Anxiety/Depression – Pain, constipation, nausea… – Electrolyte imbalance – Renal or liver failure – Infection – Nutritional deficiencies

15. Management of delirium (1) General principles – Treat reversible causes – Reassurance – child, family, staff – Calm – quiet, adequately lit, familiar people and familiar items – Avoid restraint

16. Management of delirium (2) Drugs – Manage expectations – relief of delirium vs sedation – No evidence base in children – extrapolated from adult pall care – Options: Phenothiazines e.g. haloperidol, levomepromazine Benzodiazepines e.g. midazolam, lorazepam Phenobarbitone

17. Summary Able to distinguish between anxiety, depression and delirium How to recognise them and approach their management in PPC

18. Questions