13.2 (17.3) Depression, demoralization, and suicidality Flashcards
List 3 negative outcomes that depression is associated with
decreased adherence to treatments* increased inpatient stays thoughts of suicide* poorer survival* decreased QOL* Others: social withdrawal reduced integration of information reduced tolerance for symptoms
What are two cardinal features of depression?
How long do depression symptoms have to be present to diagnose a major depressive disorder?
depression (low mood) and anhedonia
2 weeks
List four somatic symptoms of disease that overlap with depression
changes in appetite/weight, concentration issues, sleep, energy, and fatigue
MSIGECAPS —> SECAP
Debate exists around including/excluding somatic symptoms from criteria when diagnosing depression in the medically ill.
What are the 2 schools of thought aroud this?*
- Somatic symptoms correlate highly with other symptoms, so add worthwhile contribution to diagnostic accuracy.
- Endicott (1984) suggests alternatives for somatic symptoms in medically ill:
- social withdrawal or reduced talkativeness
- depressed demenour or appearance
- loss of responsiveness
- brooding, self-pity, or pessimism
So-Ap Res-Pes
How do the following DSM-5 diagnoses differ from MDD?
1) Depressive disorder due to another medical condition
2) Depressive disorder not elsewhere classified
3) Major depressive episode from bereavement
1) Diagnosis is a direct physiological result of conditions such as:
hypothyroidism
chronic uremia
cancer-induced cytokines
steroids
interferon-alpha
chemo
2) For brief depressive episodes or those with mixed anxiety-depressive symptoms
3) No difference: DSM-5 allows diagnosis of MDE even if symptoms result from bereavement
- What is the prevalence of depressive disorders in oncology/palliative populations?
- How can a cancer diagnosis directly and indirectly enhance the risk of depression?
- Major depression - approximately 38%
Depression spectrum disorders may be a high as 58% - Direct:
- Proinflammatory cytokines (lung, pancreas, lymphoma)
Indirect:
- Treatments with psych side effects (chemo, steroids)
- Emotional and logistical challenges that deplete patients’ material and psychological resources
Does depression directly increase the risk of cancer?
What are two mechanisms through which depression can indirectly increase the risk of cancer?
no evidence to suggest depression increases risk of cancer
but can increase risk of obesity in women which increases risk of endometrial and breast ca
can also increase rates of EtOH, smoking, physical inactivity which can increase risk of several cancers
Untreated depression has been associated with worsened medical outcomes in cancer/advanced disease.
- How does depression impact survival in cancer patients?
- How can psycho-oncology help? Does it improve survival?
- Patients who are helpless, hopeless, depressed, socially alienated/deprived have had shorter survival times.
Fatalistic and stoical attitudes may also reduce survival
- Psycho-oncology can promote coping, treat depression, improve social support.
Unclear if it can improve survival, but it did prevent development of depression.
List 3 ways that depression alters a person’s treatment adherence
box 13.2.1 (17.3.1):
- reduced understanding*
- pessimism about outcome and benefit*
- ambivalent decision making*
- decreased motivation for care and healthy behaviors
- poorer tolerance of side effects
- poorer family support and greater isolation
- reduced use of community resources
List five risk factors for depression in PC
Which is the most important risk factor?
```Box 13.2.2
1. female sex - most important risk factor
(estrogen receptors in mood regulating limbic system)*
2. younger age*
3. past history and family history of depression*
4. poor social support including family dysfunction*
5. pain and poor symptom control*
6. illness and treatment related factors
7. declining functional status
8. unaddressed existential concerns
9. comorbid neuro disorder + other metabolic/endo d/o
10. advanced disease
11. prognostic awareness of pall GOC unless positive reframing + active coping strategies
~~~
List two medical conditions that can cause depression.
List two classes of chemotherapy that can cause depression
medical conditions:
- pancreatic cancers/lung/lymphoma
- parkinson’s
- hypothyroidism*
- hypercalcemia*, pellagra,
- paraneoplastic syndromes
chemo classes:
- vinca alkaloids - vinblastine, vincristine
- taxanes - paclitaxel, docetaxel
Many medications have a direct effect on depression or its treatment. List 5.
- Interferon
- Interleukin 2 (IL-2)
- Steroids*
- Certain chemo*
- hormonal agents (tamoxifen, leuprolide)*
- antiepileptics (leviteracetam)
- anti-hypertensives (propranolol)*
- antibiotics (amphotericin)*
V - anti-hypertensive
I - abx
N - chemo (Vinka alkaloids, Taxanes)
A - steroid
E - hormone tx
What 3 cancers are linked to depression and by what mechanism is this proposed to occur
pancreatic, lung, lymphoma
increase levels of pro-inflammatory cytokines
List 3 barriers to the recognition of depression in palliative care patients
- Confouding effect of medical symptoms
- Stigma attached to mental health
- Physician focus on physical “solvable” symptoms
- For family/staff, acknowleding depression may feel like denying reality of patient’s distress or criticism of suffer’s coping
- Limited time of clinicians
- What approach is recommended to assist clinicians in recognizing depression in cancer patients
- What is a practical screening tool?
- What is 1 downside of this type of tool?
- periodic screening of all patients
- Brief self report instruments
- Will return more false positives than structured psychiatric interviews
List 2 tools that can be used to screen for depression
1. Patient health questionnaire - 9 (PHQ9) (most brief, highly reliable, widely used)* 2. Beck Depression Inventory* 3. General Health Questionnaire - 28 4. Center for Epidemiological studies - depression scale Distress thermometer (less reliable but rapid) 5. "Are you depressed" - can ID patients needing further evaluation
- Define demoralization
- Which 2 mechanisms usually protect against demoralization
- Loss of morale spans a spectrum of mental states - list these 4.*
- When is psychiatric involvement indicated?
- A state of low MORALE and poor COPING, characterized by hopelessness, helplessness, and meaninglessness from which can develop a desire to die
- a) Strong HOPE about value/worth of life (preserves meaning)
b) Robust SELF-ESTEEM (sustains self worth) - a) Disheartenment - mild loss of confidence
b) Despondency - starting to lose hope and purpose
c) Despair - all hope is lost
d) Demoralization - meaning and purpose are lost - At more severe end - when meaninglessness, pointlessness, and hopelessness all lead to suicidal thinking
List three cardinal features of demoralization
Box 13.2.3 Diagnostic criteria for demoralization syndrome
- Loss of meaning or purpose in life
- loss of hope for a worthwhile future
- sense of being trapped or pessimistic
- feel like giving up
- unable to cope with the predicament
- socially isolated or alienated
- potential for desire to die
- persists for more than 2 weeks (may be co-morbid or distinct from depressive disorders)
FS: hopeless, helpless, meaningless
List four risk factors for demoralization
1. younger age* 2. female* 3. living alone* 4. family dysfunction 5. high symptom burden* 6. use of resignation and avoidant coping 7. emotional, spiritual and practical problems 8. Physician communication of poor prognosis/pall GOC may precipitate acute demoralization
Similar to depressions
- How is demoralization measured?*
- Validated 16 item demoralization scale DS-II
How does demoralization correlate with:
1. Anxiety
2. Depression
- Trait anxiety has higher correlation (than depression) with development of demoralization due to helplessness/existential uncertainty
- Once demoralization becomes severe, clinical depression becomes more likely.
List 4 risk factors for suicidality
1. depression* 2. demoralization* 3. pain 4. poor symptom control* 5. debility 6. social isolation* 7. delirium 8. alcohol 9. substance abuse 10. past history of psych disorder 11. certain cancers (head & neck, lung) with greater physical morbidity
- How does depression impact request for euthanasia?
- How does treatment of depression impact this?
- Depressed patients are 4 times more likely to request euthanasia than non-depressed patients
- When depression is successfully treated, patient’s interest in life-sustaining therapies increases.
- List 5 “moderators” of distress associated with DHD*
- List 4 “mediators” of DHD*
FIgure 13.2.1:
1. Increase distress:
-functional limitation
-pain and other symptoms
-anhedonic depression
Decrease distress:
-social support
-spiritual well being
- Hopeless
Meaningless
Worthless
Shame
List 4 key points to assess in the suicidal patient
- WHAT: desire to die and acceptance of death when it arrives OR active suicidal thinking
- WHY: Evaluate for depression or demoralization (presence of meaninglessness, pointlessness, hopeless-helpless thinking, worthlessness) as pathways to suicidal thinking
- WHERE/HOW: Assess for modes of suicide and ask about plans to act
- WHEN: Assess for urgency -if patient appears desperate, agitated, strongly resolved to act (requires urgent management)
List four classes of drugs used to treat depression in advanced illness
SSRI - 1st line
SNRI = Serotonin and norepinephrine reuptake inhibitors
NDRI = norepinephrine and dopamine reuptake inhibitor (buproprion)
NASSA = noradrenergic and specific seritonergic antidepressants (mirtazapine)
serotonin antagonist and reuptake inhibitor - trazodone
TCA
psychostimulants
List 1 nonstandard treatment for depression in the medically ill
ketamine
Name 1 class of anti-depressants that should be avoided in palliative care patients and the reason why
MAOI’s due to risk of drug interactions, esp with opioids or other serotonergic meds
List three drugs to avoid for depression if a patient has seizures
bupropion
mirtazapine
psychostimulants
Which antidepressants can rarely exacerbate neutropenia? - name 1 class
*relevant question??
tricyclics
mirtazapine
trazodone
SSRI’s (fluoxetine, sertraline)
List 2 symptoms (beside depression) that can be treated with SNRI
neuropathic pain - duloxetine (Cymbalta) and venlafaxine (Duloxetine)
hot flashes - venlafaxine (and mirtazapine)
List two side effects of buproprion
anxiety
seizures
agitation
List 2 stimulants that may be beneficial for adjunct treatment of depression and for fatigue in the terminally ill
- Methylphenidate (Ritalin)
- Modafinil (may be better tolerated, primarily used to treat narcolepsy)
List four side effects of psychostimulants
Anorexia*
insomnia*
arrhythmia*
seizures*
Agitation*
hallucinations*
psychosis
nightmares
- What is the role for steroids in treatment of depression?
- Give examples of dosing
- What is an important side effect to watch for?
- Trial of steroids to elevate mood and overall well being may be used in patients with very short life expectancy
- Methylprednisolone 30 mg/day or dex 4mg/day
- Can cause dysphoric mood in some patients
Tamoxifen is a selective estrogren receptor modulator used to prevent recurrence or treat metastatic breast cancer
- What is the concern re tamoxifen/abiraterone and antidepressants?
- List two antidepressants that are safe to use with tamoxifen
- most antidepressants induce some inhibition of CYP2D6 which catalyzes conversion of tamoxifen/abiraterone to its active form (compromising its effect)
- avoid paroxetine, fluoxetine, sertraline (potent 2D6 inhibitors assoc with increased recurrence/mortality)
- venlafaxine (SNRI) and mirtazapine (nassa) are safe (mild 2D6 activity)
What is the concerning drug-drug interaction between irinotecan and SSRI’s?*
- Irinotecan is a colon cancer agent that requires conversion to active form by CYP system
- SSRI’s and TCA’s may increase levels of active drug through CYP interaction rarely causing rhabdomyolysis
What is serotonin syndrome?
Rare but potentially fatal autonomic dysregulation caused by excessive serotonin
List six signs or symptoms of serotonin syndrome
```Listed in order of progressive severity:
shivering
sweating
nausea
——————————–
tachycardia
mydriasis
myoclonus
hyper-reflexia
——————————–
psychomotor agitation and disorientation
metabolic acidosis
renal failure
Seizure
DIC
coma
death
~~~
WP: SHIVER
Shivering, sweating
Hyper-reflexia/myoclonus
Inc temp
Vital signs (tachy, tachypnea, hypotense)
Encephalopathy (psychomotor agitation & disorientation, seizures)
Renal failure
List 2 medications that could precipitate serotonin syndrome when given with an antidepressant
Meds with MAOI-like properties:
1. linezolid
2. procarbazine (chemo)
In rare cases, many common meds:
- opioids (esp meperidine, fentanyl, methadone)
- ondansetron
List the following for TRICYCLICS:
1. Action
2. Advantageous effects or side effects
3. Harmful side effects
4. Use in palliative care
5. Daily dose ranges
- Inhibits 5HT and NA uptake, antimuscarinic, antihistaminic, anti-alpha1
- coanalgesic, sedative
- constipation
dry mouth
urinary retention
hypotension
syncope - pain, insomnia, depression
- Amitriptyline 25-150 mg
List the following for SSRI’s:
1. Action
2. Advantageous effects or side effects
3. Harmful side effects
4. Use in palliative care
5. Daily dose ranges
- Inhibits 5HT reuptake
- Citalopram safe with tamoxifen, safer for seizure
- sexual dysfunction (5HT2a)
nausea, vomiting, diarrhea (5-HT3)
QTc prolongation at higher doses - Depression, anxiety, OCD, PTSD
- citalopram 10-60 mg
fluoxetine 10-80
paroxetine 10-60
sertraline 25-200
escitalopram 5-20
? safe with abiraterone
List the following for SNRI’s:
1. Action
2. Advantageous effects or side effects
3. Harmful side effects
4. Use in palliative care
5. Daily dose ranges
- Inhibit 5HT and NA (noradenaline) reuptake
- Co-analgesic , hot flashes
- HTN in higher doses, nausea, GI tract
- Severe depression, anxiety
- Venlafaxine 37.5-450 mg
Desvenlafaxine 50-200 (care with hepatorenal insufficiency
Duloxetine 15-60 mg
*oxford does not clarify GI tract side effect further - ?GIB vs other GI
List the following for Buproprion:
1. Action
2. Advantageous effects or side effects
3. Harmful side effects
4. Use in palliative care
5. Daily dose ranges
- Inhibits dopamine and NA reuptake
- Improve attention and concentration
Reduce fatigue
Lowest impact on sexual function - Anxiety
seizures
agitation - Depression, fatigue
- Buproprion 150-450 mg daily
List the following for mirtazapine (noradrenergic and specific serotonergic antidepressants):
1. Action
2. Advantageous effects or side effects
3. Harmful side effects
4. Use in palliative care
5. Daily dose ranges
- Increases 5HT and NA activity (like SNRI), antihistaminic
- Stimulates appetite, helps sleep
- dry mouth, drowsiness, higher risk of seizure
- depression, anxiety, appetite and weight gain, insomnia
- Mirtazapine 15-60 mg
List the following for SARI’s (serotonin antagonists and reuptake inhibitors) i.e. Trazodone:
1. Action
2. Advantageous effects or side effects
3. Harmful side effects
4. Use in palliative care
5. Daily dose ranges
- Increases 5HT activity, anticholinergic
- Helps sleep
- Dry mouth (anti-cholinergic meds)
Constipation
Urinary retention
Drowsiness - Sleep
Depression - Trazodone 50-300mg
List the following for psychostimulants:
1. Action
2. Advantageous effects or side effects
3. Harmful side effects
4. Use in palliative care
5. Daily dose ranges
- Increase dopamine activity
methylphenidate: NE, dopamine reuptake inhibitor
modafinil: inc catecholaminergic effect, dec GABA release - Counter opioid sedation, alertness, counter fatigue, rapid effect
- agitation
insomnia
anorexia
seizures
hallucinations
psychosis
arrhythmia
nightmares - depression
opioid sedation - Methylphenidate 5-60 mg
Modafinil 100-400 mg
Dextroamphetamine 5-60 mg
List 5 psychological treatments shown to be helpful in treating depression
- Individual psychotherapies (i.e. psychoeducation)
- Behavioural activation strategies
- Couple therapy - helps when body image changes/sexuality affected (ED, dyspareunia)/psych demands. Promotes effective mutual support/intimacy/prevents demoralization/depression.
- Group therapy
-cognitive existential or supportive-expressive - Family therapy
-prevents prolonged grief disorder or complicated grief
What is the pharmacological treatment for demoralization
Where comorbid major depression and demoralization exist - give medication for treatment of depression
If demoralization alone - treatment is psychotherapeutic (no current evidence for antidepressants/other meds)
List two treatments for demoralization
dignity therapy
meaning centred therapy
- What is dignity therapy?
- List 5 goals of dignity therapy
- Brief focused intervention near end of life designed to address psychosocial and existential distress.
Seeks to celebrate life and affirm worth of each person, address demoralization and enrich life lived. - a) Sustain generativity and continuity of self (meaning)
b)Maintain pride and hope (hope)
c)Preserve patient’s cherished roles (helplessness)
d)Alleivate concerns about being a burden on others (helplessness)
e) If desired, leave a legacy document of accomplishments/values in life
- What is the goal of meaning-centred therapies?
- How is this accomplished?
- List 3 models of MCT
- To review concepts/sources of psycholgical meaning and value together with the impact of pall care, and acknowledge the finiteness of life and therefore highlight its value and worth.
- creativity, good deeds, appreciation of nature, art and humour, focus on taking stock of depth of meaning that sustains worthwhile living
- CALM (cancer and living meaningfully)
Psychodynamic life review
meaning and purpose therapy
Many who complete suicide have recently denied SI and have not made prior attempts.
List three warning signs of imminent suicidality. List the primary action that needs to be taken if this is identified
agitation
increasing anxiety
desperation
easy access to mode of dying
admission to hospital/certification
What are 5 key approaches to patients who express a desire for hastened death in the hospice/pall care setting?
- Therapeutic communication
- Empathic responsiveness
- Active listening
- Management of realistic expectations
- Permission to discuss psychological distress
- Psychiatric referral if needed
1) Whether somatic symptoms are included/excluded when diagnosing depression in the medically ill, which 2 features are central to the diagnosis of MDE?
2) Which 2 combinations of symptoms highly associated with depression can be readily identified/excluded in patients with physicial illness?
- pervasive anhedonia
sustained low mood - a) pessismism + worthlessness
b) pessimism, loss of interest, thoughts of death
(Demoralization)
